Medial Ulnar Collateral Ligament Research Articles

Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years.

Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management. This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation. Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022. Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated. Systematic review. Level 4. Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing. Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores. Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.

UCL Throwing Injuries in Nonprofessional Baseball Players: A 14-Year Retrospective Study.

This study evaluated treatment modality (surgical vs nonoperative) of medial ulnar collateral ligament (UCL) injuries in nonprofessional throwing baseball athletes by comparing type, severity, and location of UCL injury. Baseball players with closed medial epicondyle physes and concomitant throwing-related UCL injury will be more likely to undergo surgical intervention than players with open medial epicondyle physes. Retrospective. Level 5. A total of 119 baseball players with a mean age of 16.9 ± 2.5 years (range, 11-25 years) were included in the study. Datapoints included sex, age at time of injury, severity, and location of UCL injury, growth plate status, operative versus conservative management, and concomitant flexor forearm injury. A total of 75 players were treated conservatively; 43 underwent UCL reconstruction (UCL-R), and 1 had an unknown treatment outcome. No significant difference was found for age related to treatment type, UCL-R (17.2 ± 2.2) versus conservative treatment (16.8 ± 2.6). Athletes with closed medial epicondylar growth plates were more likely to undergo UCL-R than athletes with open medial epicondylar growth plates (P = 0.02). There were no significant differences between UCL injury location (42 distal, 37 proximal, 18 combined tear locations, 11 complete tears, and 11 intact UCLs with inflammation) by treatment type (P = 0.09). There was a significant difference for UCL severity (11 complete tears, 96 partial tears) by treatment type (P = 0.03). Nonprofessional athletes with closed medial epicondylar growth plates and throwing-related UCL injuries were more likely to be treated surgically. Baseball athletes with partial tears, if skeletally immature, require further long-term evaluation. Continued knowledge gains in this area of throwing medicine will further improve our treatment algorithms in nonprofessional baseball players.

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.

Intermediate Outcomes of Medial Ulnar Collateral Ligament Reconstruction Using Gracilis Allograft in Adolescent Patients.

Autograft palmaris has been the primary choice for the reconstruction of the medial ulnar collateral ligament (UCL) in the elbow. Agenesis of the palmaris tendon is not rare, and outcomes of allograft reconstruction in the breadth of athlete types found in the adolescent population are lacking. Allograft tendon reconstruction of the medial UCL in the young elbow would have low failure rates and satisfactory outcome scores. Case series; Level of evidence, 4. The records of patients who underwent allograft medial UCL reconstruction (UCLR) by a single surgeon between 2009 and 2019 were reviewed. Patient-reported outcome scores in adolescent patients obtained at a minimum 4-year follow-up (for intermediate assessment) were recorded, with no exclusion according to sex or sport type. Outcomes included the Timmerman-Andrews score, the Single Assessment Numeric Evaluation (SANE), and the Conway-Jobe score. Of 29 patients who underwent allograft UCLR, 10 adolescents (40% women; mean age at surgery, 15.8 years [age range, 15-17 years]) met the inclusion criteria and were included in the study. The mean follow-up was 8 years (range, 4.3-11.9 years). There were 4 overhead athletes (baseball, water polo) and 6 impact sports athletes (motocross, gymnastics, wrestling, and soccer). The mean SANE score was 86.3, and the mean subjective Timmerman-Andrews score was 92.5. The Conway-Jobe score was "excellent" in 7 of 10 participants; nonetheless, 3 elected not to return to sport (2 for reasons unrelated to the elbow). No patients experienced loss of range of motion, contracture, or ulnar nerve neuropathy. There was 1 patient with early failure (10%) who required revision reconstruction . Allograft reconstruction for medial UCL instability in adolescent patients from sport and trauma mechanisms demonstrated excellent patient-reported functional scores in this study. If the patient and surgeon desire to avoid autograft morbidity or agenesis of the palmaris longus, allograft tendon UCLR appears viable for both the throwing and the high-impact adolescent athlete, regardless of sex.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction Between Palmaris Longus Autograft and Knee Medial Collateral Ligament Allograft

Background: Medial ulnar collateral ligament (mUCL) injury can cause significant pain and alter throwing mechanics. Common autograft options for mUCL reconstruction (UCLR) include the palmaris longus (PL) and hamstring tendons. Allograft use may reduce donor site morbidity and decrease function related to PL autografts. Purpose: To compare varus stability and load to failure between a novel allograft for UCLR—knee medial collateral ligament (kMCL)—and a PL autograft in human donor elbow specimens. Study Design: Controlled laboratory study. Methods: A total of 24 fresh-frozen human elbows were dissected to expose the mUCL. Medial elbow stability was tested with the mUCL intact (native), deficient, and reconstructed utilizing the humeral single-docking technique with either a (1) kMCL allograft (n = 12) or (2) a PL autograft (n = 12). A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion tracking cameras. The elbow was cycled through a full range of motion 5 times. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion, and failure modes were recorded. Results: The mUCL-deficient elbows demonstrated significantly greater valgus rotation compared with the intact and reconstructed elbows at every flexion angle tested (10°-120°) ( P <.001). Both kMCL- and PL-reconstructed elbows exhibited significantly higher mean valgus rotation compared with the intact state between 10° and 40° of flexion ( P < .01). There were no significant differences in valgus rotation at any flexion angle between the kMCL and PL graft groups. When loaded to failure, elbows reconstructed with both kMCL and PL grafts failed at similar torque values (18.6 ± 4 and 18.1 ± 3.4 N·m, respectively; P = .765). Conclusion: Fresh-frozen and aseptically processed kMCL allografts demonstrated similar kinematic and failure properties to PL tendon autografts in UCL-reconstructed elbows, although neither graft fully restored kinematics between 10° and 40°. Clinical Relevance: Prepared kMCL ligament allografts may provide a viable graft material when reconstructing elbow ligaments while avoiding the potential complications related to PL autografts— including donor site morbidity.

The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players

Background: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). Purpose: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. Results: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P = .006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P = .030). Players of both groups had similar dominant UCL thickness (P = .161), ulnohumeral joint space at rest (P = .321), space under stress (P = .498), and laxity (P = .796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs –0.60 mm, respectively; P = .038) and a greater increase in relative median UCL thickness (1.35 vs –0.35 mm, respectively; P = .045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P = .004). No differences in ulnohumeral stress spacing or laxity were detected. Conclusion: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

High variability among surgeons in evaluation, treatment, and rehabilitation of medial ulnar collateral ligament injuries

BackgroundThe incidence of elbow medial ulnar collateral ligament (MUCL) injuries has been increasing, leading to advances in surgical treatments. However, it is not clear that there is consensus among surgeons regarding diagnostic imaging, the indications for acute surgery and postoperative rehabilitation. Hypothesis/PurposeThe purpose of this study is evaluate surgeon variability in the presurgical, surgical, and postsurgical treatment of MUCL injuries regarding the imaging modalities used for diagnosis, indications for acute surgical treatment, and postoperative treatment recommendations for rehabilitation and return to play. Our hypothesis is that indications for acute surgical treatment will be highly variable based on MUCL tear patterns and that agreement on the time to return to play will be consistent for throwing athletes and inconsistent for non-throwing athletes. MethodsA survey developed by six orthopedic surgeon with expertise in throwing athlete elbow injuries was distributed to 31 orthopedic surgeons who routinely treat MUCL injuries. The survey evaluated diagnostic and treatment topics related to MUCL injuries, and responses reaching 75% agreement were considered as high-level agreement. ResultsTwenty-four surgeons responded to the survey, resulting in a 77% response rate. There is 75% or better agreement among surveyed surgeons regarding acute surgical treatment for distal full thickness tears, ulnar nerve transposition in symptomatic patients or with ulnar nerve subluxation, postoperative splinting for 1-2 weeks with initiation of rehabilitation within 2 weeks, the use of bracing after surgery and the initiation of a throwing program at 3 months after MUCL repair with internal brace by surgeons performing 20 or more MUCL surgeries per year. There were a considerable number of survey topics without high-level agreement, particularly regarding the indications for acute surgical treatment, the time to return to throwing and time return to play in both throwing and non-throwing athletes. ConclusionThe study reveals that there is agreement for the indication of acute surgical treatment of distal MUCL tears, duration of bracing after surgery, and the time to initiate physical therapy after surgery. There is not clear agreement on indications for surgical treatment for every MUCL tear pattern, return to play time for throwing, hitting and participation in non-throwing sports.

Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair

To evaluate the incidence of early postoperative complications and revision surgery in patients who underwent primary medial ulnar collateral ligament (MUCL) repair with minimum of 2-year follow-up. A retrospective review of a national insurance database was conducted to identify patients with MUCL injuries who underwent primary MUCL repair between 2015 to 2020 with minimum 2-year follow-up. Patients >40 years of age and those who had concomitant elbow fractures or dislocations, lateral UCL injures, medial epicondylitis, elbow arthritis, or a history of previous elbow injury/surgery were excluded. The number of patients who underwent a concomitant ulnar nerve procedure (transposition or decompression) during the primary MUCL repair was recorded. Complications within 90 days of surgery and the incidence and timing of subsequent ipsilateral ulnar nerve surgery or revision MUCL surgery were assessed. A total of 313 patients (63.6% male) were included. The mean age was 20.3 ± 6.9 years, and mean follow-up was 3.7 ± 1.3 years. Concomitant ulnar nerve transposition or decompression was performed in 34.2% (N=107). The early postoperative complication rate was 7.3% (N= 23). The most common complication was ulnar neuropathy (5.8%, N= 18). Wound complications, elbow stiffness, and medial epicondyle fractures were much less common (N= 5). Sixteen of 18 (88.9%) patients with postoperative ulnar neuropathy underwent transposition or decompression at the time of primary repair. Of these 18 patients, 5 (27.8%) underwent a subsequent ulnar nerve surgery (1 primary and 4 secondary), with the majority occurring within 6 months. The incidence of revision MUCL surgery was low (1.0%, N=3), with all 3 patients undergoing MUCL reconstruction. There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. All 3 (1.0%) MUCL revisions underwent reconstruction. Level IV, therapeutic case series.

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]

Poster 206: What are the Indications for Medial Ulnar Collateral Ligament Surgery in Baseball Players? An MRI Case-based Study

Objectives: Ulnar Collateral Ligament (UCL) tears are common in baseball players. When non-operative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics, or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs reconstruction. Methods: Twenty-six orthopaedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intra-operatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (peri-ligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, mid-substance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95%CI) helped identify significant predictors for both queries. Results: The odds of recommending surgical treatment compared to non-operative treatment were 2.4x more likely for a proximal partial-thickness tear, 3.2x for distal partial-thickness tear, 5.1x for distal full- thickness tear, and 7.0x for proximal full-thickness tear (p<0.001). Significant indications for repair included distal partial (OR=1.6, 95%CI 1.0, 2.1, p<0.001) and full-thickness tears (OR=1.7, 95%CI 1.1, 2.3, p<0.001). Repair was 3x less likely recommended for mid-substance full-thickness tears (OR=3.0, 95%CI - 5.0, -1.0, p=0.004). Ultrasound stress testing was requested in 78% of partial tears. Conclusions: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial- thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete mid-substance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes. [Table: see text]

Paper 21: Functional Outcomes of Primary Ulnar Collateral Ligament Repair with Internal Bracing in Athletes

Objectives: The ulnar collateral ligament (UCL) is the primary restraint to valgus stress in the elbow. Injury to this ligament can occur in the setting of acute trauma as well as chronic overuse as seen in baseball players and other overhead athletes. Injury to the UCL continues to be a major source of morbidity in overhead-throwing athletes, with the incidence of UCL tears increasing dramatically over the past 15 years. UCL reconstruction using palmaris longus or hamstring autograft (also known as Tommy John surgery) has been considered the gold standard for the surgical treatment of symptomatic UCL injuries in overhead athletes for decades. Recently, there has been a renewed interest in UCL repair. In 2016, Dugas et al described the novel use of a collagen-dipped internal brace to augment UCL repair with encouraging biomechanical results from a cadaveric study. To date, only two studies have reported outcomes for this novel approach to UCL repair with internal brace (IB) augmentation, both with encouraging results. It is thought that the main advantages of UCL repair with IB augmentation compared to UCL reconstruction are comparable return to sport rates with a more rapid postoperative recovery, as well as restoration of normal anatomy that eliminates the need for an autograft and the associated complications of graft harvesting. Given the paucity of data examining this new surgical approach, this study seeks to add clinical outcome data for UCL repair to the scientific literature. The goal of this project is to evaluate functional outcomes following primary ulnar collateral ligament repair using internal brace augmentation and to describe new advancements in the surgical technique for this procedure. Methods: Approval was obtained from the Columbia University Irving Medical Center Institutional Review Board. A retrospective review of the electronic medical records of all consecutive patients who underwent medial UCL repair with internal brace augmentation between 2016 and 2022 was performed. All procedures were performed at a single tertiary institution and all patients were under the direct medical care of the senior author. Only patients with a focal UCL injury, such as a distal or proximal avulsion tear, were selected for UCL repair with internal brace augmentation. Evidence of chronic attritional disease, including calcification on MRI, or extensive ligamentous injury were contraindications to UCL repair. Additionally, only patients undergoing primary UCL repair with internal brace augmentation were included; those with prior UCL reconstructions or repairs were excluded as were patients with insufficient clinical follow-up data. Included in the chart review were patient demographics, level of sport, injury characteristics, preoperative imaging findings, operative data, and postoperative clinical outcomes including complications and reoperations. Patient reported outcomes were collected from the Pitch Registry, a national database maintained by Major League Baseball (MLB). Primary outcomes for this study include the ability to return to play (RTP) at the same previous level or higher, the time to return to competition, complications, and reoperations. Results: A total of 56 patients were included in this study (mean age at surgery was 19.5 ± 4.5 years; 55 men and 1 woman). The majority were baseball players (n=52) of which 43 were pitchers, while the remaining athletes played football, wrestled, or competed in Jujitsu. Twenty-eight were high school athletes, 23 played at the collegiate level, 4 played recreationally, and 1 played professionally. Symptoms of UCL injury preceded surgery by an average of 7.5 ± 15.0 months. The UCL was partially torn in 39 patients and fully torn in the remaining 17 patients, and it was torn proximally in 18, distally in 37, and mid-substance in 1 patient. The mean preoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) score was 61.5 ± 15.3, the mean preoperative American Shoulder and Elbow Surgeons (ASES) score was 71.6 ± 14.9, and the mean preoperative Youth Throwing Score (YTS) was 40 ± 14. A concomitant arthroscopic osteophyte debridement and synovectomy was performed in 10 cases and a concomitant ulnar nerve transposition was performed in 4 cases. There were no intra-operative complications. The mean length of follow-up was 12.1 ± 7.1 months. Of the total cohort, 51 (91.0%) patients were able to return to play at an average of 7.8 ± 2.4 months. There were 4 reoperations (7.1%) including a single revision UCL reconstruction, 2 ulnar nerve transpositions, and 1 arthroscopic osteophyte debridement. Conclusions: Primary UCL repair with internal brace augmentation is a viable alternative to UCL reconstruction as supported by a rapid return to play and a low complication rate. There remains a paucity of data examining this encouraging and novel surgical approach. Additional data and analysis examining functional outcomes and optimal patient selection will be critical to address the rising epidemic of UCL injuries in young athletes.

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.

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.

What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study.

Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction. Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries. The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P<.001). Significant indications for repair included distal partial (OR=1.6, 95% CI 1.0, 2.1, P<.001) and full-thickness tears (OR=1.7, 95% CI 1.1, 2.3, P<.001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR=3.0, 95% CI -5.0, -1.0, P=.004). Ultrasound stress testing was requested in 78% of partial tears. Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

안쪽곁인대 불안정성이 야구선수들의 그립관련 근력 및 경기력에 미치는 영향

이 연구는 야구선수들을 대상으로 안쪽곁인대 불안정성이 그립관련 근력 및 경기력에 미치는 영향을 알아보고자 실시되었다. 대학교 야구선수 총 67명을 대상으로 실시하였으며, 안쪽곁인대 통증, 손상경력 및 불안정성 검사를 통하여 정상집단과 안쪽곁인대 불안정성집단으로 구분하였다. 신체적 특성, 통증 유무, 경기관련 요인(경기 불안감 및 투구 속도)을 측정한 결과는 다음과 같다. 안쪽곁인대 불안정성에 따른 신체적 특성은 유의한 차이가 나타나지 않았으며, 안쪽곁인대 불안정성을 가진 집단의 통증은 정상집단에 비하여 유의하게 높게 나타났다(p.001). 그립관련 근력은 팔꿈치 폄력과 악력이 유의한 차이를 나타냈으며, 안쪽곁인대 불안정성을 가진 집단이 정상집단에 비하여 유의하게 낮게 나타났다. 경기관련 요인 중 투구 속도가 유의한 차이를 나타냈으며, 안쪽곁인대 불안정성을 가진 집단이 정상집단에 비하여 유의하게 낮게 나타났다. 안쪽곁인대 불안정성은 통증유무와 유의한 양의 관련성(p.001)을 나타내고, 투구 속도와 유의한 음의 관련성(p.05)을 나타냈다. 통증 유무는 팔꿈치 폄력(p.001) 및 악력(p.05)과 유의한 음의 관련성을 나타냈다. 팔꿈치 굽힘력은 손목 굽힘/폄력(p.01) 및 악력(p.001)과 유의한 양의 관련성을 나타내고, 경기 불안감과 유의한 음의 관련성을 나타냈다(p.05). 손목 굽힘력은 손목 폄력 및 악력과 유의한 양의 관련성을 나타냈고(p.001), 악력은 투구 속도와 유의한 양의 관련성을 나타냈다(p.05). 이상의 결과를 요약해보면, 안쪽곁인대 불안정성과 악력은 투구 속도에 영향을 주는 것으로 나타났으므로 안쪽곁인대 불안정성을 예방하고 관리하면서 그립관련 근력을 증가시킬 수 있는 훈련 프로그램이 필요할 것으로 생각된다.

The Rate of Medial Ulnar Collateral Ligament Repair Is Increasing While Reconstruction Remains the Most Common Procedure Overall Among Early-Career Orthopaedic Surgeons

The Rate of Medial Ulnar Collateral Ligament Repair Is Increasing While Reconstruction Remains the Most Common Procedure Overall Among Early-Career Orthopaedic Surgeons

Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

Background: Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear. Purpose: To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries. Results: A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757). Conclusion: For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles’ tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles’ tendon, and deltoid ligament repair demonstrate improved time-zero biomechanical and promising short- to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint overconstraint, nerve paresthesia, and infection. Level of EvidenceLevel V, expert opinion.

Radiographic Description of Soft Tissue Attachments around the Elbow.

Quantitatively define the radiographic locations of the major soft-tissue attachments about the elbow. In 10 cadaveric elbows, the attachments of the medial ulnar collateral ligament, lateral ulnar collateral ligament, annular ligament, triceps, and biceps were marked with radiopaque spheres. Measurements were made on calibrated AP and lateral fluoroscopic images from known osseous landmarks. On AP radiographs; the anterior bundle of the MUCL (aMUCL) measured 28.6mm (95% CI, 27. 5-29.8mm) from the humeral attachment to the midpoint of the MUCL ridge on the ulna and 14.3mm, (95% CI 13.0-15.5) to the olecranon. The LUCL was 39.9mm (95% CI, 38.6 - 41.1mm) from the humeral attachment to the supinator crest attachment and 8.9mm (95% CI, 8.1-9.8mm) to the lateral epicondyle. On the lateral radiographs, the humeral attachment of the aMUCL to the medial coronoid was 27.1mm (95% CI, 25.9-28.2mm) and 9.3mm (95%CI, 17.5 -21.2mm) to the tip. The LUCL humeral attachment to the supinator crest was 45.4mm (95%CI, 44.1-46.8mm). The LUCL humeral attachment was located 8.9mm (95%CI, 8.0-9.7mm) posterior from the anterior humeral line. The soft-tissue attachments about the elbow were reproducibly demonstrated on radiographs in relation to osseous landmarks and radiographic lines. The radiographic relationships will allow for improved identification of the ligament and tendon attachment sites of the elbow for intraoperative assessment and postoperative evaluation following reconstruction.

Biomechanical Effect of Differential Tensioning on Suture-Augmented Ulnar Collateral Ligament Reconstruction of the Elbow

Background: Medial ulnar collateral ligament (mUCL) reconstructions are becoming increasingly prevalent among the overhand throwing population. Suture tape augmentation has the potential to provide biomechanical advantages over standard docking reconstruction. However, the optimal tensioning of the suture augmentation technique has not yet been evaluated. Purpose: To compare the subfailure biomechanical performance and graft strain of a standard docking mUCL reconstruction to an mUCL reconstruction using suture tape augmentation tensioned with 1 mm or 3 mm of laxity. Study Design: Controlled laboratory study. Methods: A total of 18 cadaveric elbows were dissected to the mUCL anterior band and biomechanically assessed via a valgus torque protocol to failure. Elbows were randomly assigned to be reconstructed via (1) a standard docking technique, (2) a suture-augmented reconstruction with 1-mm laxity, or (3) a suture-augmented reconstruction with 3-mm laxity. Reconstructed elbows were then subjected to the same loading protocol. Subfailure mechanical properties, failure mode, and mUCL/palmaris strain were assessed. Results: All reconstruction groups had decreased rotational stiffness, torque at 5° of angular rotation, and resilience compared with matched native controls. There were no differences in transition torque between groups. The failure mode of suture-augmented specimens was most often due to bone tunnel failure or reaching the maximum allowable angular displacement. In native controls or docking reconstructions, the primary failure mechanism was in the ligament or graft midsubstance. There were no significant differences in strain on the reconstructed or suture-augmented groups at any laxity compared with native controls. Conclusion: Suture augmentation results in similar subfailure joint biomechanical properties as the standard docking reconstruction procedure at both laxity levels in a cadaveric model. There are improvements in the failure mode of suture-augmented specimens compared with standard docking. Graft strain may be modestly reduced in the 1-mm laxity group compared with other reconstruction groups. Clinical Relevance: Suture augmentation at both 1-mm and 3-mm laxity appears to offer similar advantages in subfailure biomechanics to standard docking reconstruction of the mUCL, with some improvements associated with failure mode. Strain data suggest a potential avoidance of graft stress shielding when tensioning the suture augmentation to 3-mm laxity, which is not as apparent with 1-mm laxity.