Medial Ulnar Collateral Ligament Research Articles

Medial Collateral Injury in the Young, Nonprofessional Athlete: Surgical Repair

Injuries to the medial ulnar collateral ligament (UCL) have traditionally been treated with reconstructive methods aimed at recreating medial elbow stability. At our practice in Birmingham, Alabama, thousands of overhead athletes have been treated with UCL reconstruction regardless of the injury severity or the patient being treated. Reconstruction techniques include autograft harvest and implantation at the native UCL origin and insertion. Rehabilitation, graft maturation, and return to play can take anywhere from 12-18 months on average. We have experienced excellent long-term outcomes with 84% return to play at the same or higher level at an average of 11.4 months. of UCL injuries has reached near epidemic proportions with a fiercely competitive youth baseball culture in America. The number of UCL reconstructions at our institution alone nearly tripled at the youth and high school level between 1998 and 2008. The young, nonprofessional athletic population accounts for a significant number of UCL injuries being managed nation wide each year, and until recently, with a gold standard ligament reconstruction approach. With advancements in suture anchor technology we began to ask whether the severity of injury or patient characteristics, such as end-avulsions in the young athlete, called for alternative fixation methods. This led us to create a novel repair and augmentation construct that involved suture fixation of the avulsed native UCL to bone followed by reinforcement of the ligament along its entirety.is our recommendation that patients identified as candidates for UCL repair have intraoperative confirmation of ligament end-avulsions or partial thickness tears with minimal midsubstance damage. This article highlights our criteria for patient selection and reviews our newly described technique of repair.

Cubital Tunnel Syndrome in the Athlete

Cubital tunnel syndrome is the most common site of ulnar nerve compression and affects the general population and athletes, alike. When ulnar neuropathy is encountered, an understanding of the pathology, a deliberate clinical approach to the patient, and the usage of diagnostic studies aid in synthesizing a successful treatment plan. Nonoperative management is recommended for patients with mild, transient symptoms; operative intervention is performed on those that fail nonoperative modalities or present with moderate to severe pathology. When examining the overhead athlete, it is equally important to evaluate the competency of the medial ulnar collateral ligament in the setting of ulnar neuropathy. This article will discuss cubital tunnel syndrome as it pertains to both the general population and to the athletic population as well as describe our preferred operative techniques and recommended postoperative protocols.

Changes in pitching mechanics after ulnar collateral ligament reconstruction in major league baseball pitchers

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball pitchers. Variations in pitching mechanics before and after UCL reconstructive surgery are not well understood. Publicly available pitch tracking data (PITCHf/x) were compared for all Major League Baseball pitchers who underwent UCL reconstruction between 2008 and 2013. Specific parameters analyzed were fastball percentage, release location, velocity, and movement of each pitch type. These data were compared before and after UCL reconstructive surgery and compared with a randomly selected control cohort. There were no statistically significant changes in pitch selection or pitch accuracy after UCL reconstruction, nor was there a decrease in pitch velocity. The average pitch release location for 4-seam and 2-seam fastballs, curveballs, and changeups is more medial after UCL reconstruction (P < .01). Four-seam fastballs and sliders showed decreased horizontal breaking movement after surgery (P < .05), whereas curveballs showed increased downward breaking movement after surgery (P < .05). Pitch selection, pitch velocity, and pitch accuracy do not significantly change after UCL reconstruction, nor do players who require UCL reconstruction have significantly different pitch selection, velocity, or accuracy than a randomly selected control cohort. Pitch release location is more medial after UCL reconstruction for all pitch types except sliders. Breaking movement of fastballs, sliders, and curveballs changes after UCL reconstruction.

Osseus Vascularity of the Medial Elbow Following Ulnar Collateral Ligament Reconstruction: A Comparative Analysis of the Docking and Figure of Eight Techniques

Objectives:The rate of revision medial ulnar collateral ligament (UCL) reconstruction continues to rise annually, and two common modes of failure for are inadequate healing at the bone-tendon interface or bony fracture through drill tunnels. Although, vascularity may play a critical role in these processes, the intra-osseous blood flow to the medial epicondyle (ME) and sublime tubercle (ST) remains undefined. The purpose of this work was to better understand the vascularity of the ME and ST at baseline and to quantify vascular disruption caused by tunnel drilling for the two most common UCL reconstruction techniques: the Figure of Eight and Docking.Methods:Eight matched pairs (16 total specimens) of fresh-frozen cadaveric upper extremities were randomized to one of the two study groups: Docking or Figure of Eight UCL reconstruction. One elbow in each pair underwent drilling of the medial epicondyle and sublime tubercle by the assigned technique, while the contralateral elbow underwent surgical exposure without drilling to serve as a matched control. For all specimens, the brachial artery was cannulated 10 cm distal to the greater tuberosity, and the ulnar artery was cannulated 10 cm proximal to the wrist. All identified remaining vessels were tied off. Pre- and post- gadolinium MRI scans were performed on all study elbows to quantify intra-osseous vascularity by contrast enhancement, which was compared to the contralateral elbow as a matched control. Intra-osseous flow is quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, Colorado). Following MRI, contrast-enhanced polyurethane latex was injected into all vessels and CT with 3D reconstruction and gross dissection was performed to correlate findings with the MRI and assess vessel integrity.Results:MRI quantification revealed drilling of the ulnar tunnels (which was the same for each group) had a minimal impact on intra-osseous vascularity of the ulna with maintenance of 96% and 99% (p=0.448) of blood flow for the Docking and Figure Eight techniques respectively (Table 1). However, perfusion to the medial epicondyle was reduced 14% (to 86% of baseline) for the Docking Technique and 60% (to 40% of baseline) for the Figure Eight technique (Figure 1). This resulted in a mean difference of 46% in reduced perfusion between the two techniques (p=0.012). Subsequent CT analysis and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the medial epicondyle for the Figure of Eight Technique (Figure 1).Conclusion:Although tunnel drilling in the sublime tubercle appears to have minimal effect on intra-osseous vascularity of the proximal ulna, both the Docking Technique and the Figure of Eight Technique reduce flow in the medial epicondyle. This reduction is four times greater for the Figure of Eight Technique, and these findings may have important implications for UCL reconstruction surgery.

Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers

Background: A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries. Purpose: To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months’ rest when attempting a return to a throwing rehabilitation program. Results: Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) (P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears (P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater (P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management. Conclusion: In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. Thus, tear location should be considered when deciding between operative and nonoperative management.

Paper #45 - Kinematics of the ulna with medial ulnar collateral ligament insufficiency

Paper #45 - Kinematics of the ulna with medial ulnar collateral ligament insufficiency

Common injuries among javelin throwers: a 10-year overview (2007-2016)

The sport of javelin throwing is a popular track and field competition enjoyed by many spectators and athletes and performed at both national and international levels. It has gained popularity in the IAAF (International Association of Athletics Federation) recognised competitions including the Olympic Games. Like athletes in all sports, javelin throwers are prone to injuries. This review was undertaken to provide an overview of the common javelin throwing injuries recorded internationally during 2007 to 2016. A systematic review of literature following the PRIMSA guidelines from 2007 to 2016 was used. Records were appraised according to the modified Downs and Black Appraisal Scale. The literature review identified 1710 English records. After the application of the exclusion criteria, 12 papers were included in the study. Javelin throwers experience a high prevalence of shoulder, elbow, lower back and knee injuries. The most common type of injury was the medial ulnar collateral ligament sprain, commonly known as javelin thrower’s elbow. The primary cause of injuries was poor throwing biomechanics that led to compensatory movement patterns, resulting in synergistic muscle dominance. The need for prospective studies is recommended.Keywords: Javelin throw, injuries, biomechanics.

Isolated ligamentous injury can cause posteromedial elbow instability: a cadaveric study

Elbow posteromedial rotatory instability (PMRI) is known to occur with fracture of the anteromedial coronoid and injury to the posterior bundle of the medial ulnar collateral ligament (pMUCL). However, whether instability results from isolated pMUCL injury remains unclear. The purpose of this study was to quantify displacement about the ulnohumeral joint to evaluate whether isolated sectioning of the pMUCL results in elbow PMRI. Nine cadaveric elbows underwent movements simulating PMRI by application of axial compression with varus and internal rotation moments. Gapping values at both the proximal and distal aspects of the medial ulnohumeral joint were then recorded for "intact" and "pMUCL-sectioned" elbows at positions of 30°, 60°, and 90° of flexion. After pMUCL transection, torsion increased by 2.6° ± 0.7° (P = .054) at 30° and 4.5° ± 1.2° (P = .039) at 60° of flexion. Proximal ulnohumeral joint gapping also increased at 30° (1.4 ± 0.4 mm; P = .039), 60° (1.5 ± 0.6 mm; P = .039), and 90° (1.5 ± 0.7 mm; P = .017), respectively. No increases in distal ulnohumeral gapping occurred at any angle of flexion. Sectioning of the pMUCL results in significant increases in torsion and displacement about the proximal ulnohumeral joint. Our findings demonstrate that elbow PMRI can occur secondary to isolated ligamentous injury. Clinicians mindful of this previously unrecognized role of the pMUCL as a stabilizer may wish to consider methods of restoring pMUCL integrity when treating medial elbow instability.

The Prevalence and Clinical Characteristics of Medial Epicondyle Apophysitis in Juvenile Baseball Player - Ultrasonographic Assessment of 2,926 Cases

Objectives:Apophysitis of humeral medial epicondyle, often referred to as “Little Leaguer’s Elbow, is one of the major throwing injuries in juvenile baseball players as common as osteochondritis dissecans of humeral capitellum. Repetitive valgus stress to the skeletally immature elbow can result in fragmentation, hypertrophy, or separation of the medial epicondyle apophysis, and these injuries may induce elbow pain and adversely influence on elbow function and throwing performance. Although several reports have described various morphological variations of the medial epicondyle apophysis, little is known about the natural course and clinical significance of these variations. The purpose of this study was to investigate the prevalence of these variations in each age group and clarify the association with elbow pain using the large epidemiologic data from medical check-ups of juvenile baseball players.Methods:Of 3,626 juvenile baseball players aged 6 to 17 years, 2,926 players were enrolled in this study. Experience of elbow pain was rated by self-completed questionnaires. Ultrasonographic assessment was used to assess the morphological variations of the antero-inferior medial epicondyle (MEC) and humeral capitellum. Regarding MEC lesion, enthesis of medial ulnar collateral ligament (MUCL) was classified into four types: normal, irregular (IR), fragmentation (FG), and hypertrophy (HT). Osteochondral lesion (OCL) of humeral capitellum was judged by the irregularity or fragmentation of subchondral bone. The prevalence of these lesions was investigated in each age group and evaluated the influence on elbow pain using multivariable logistic regression analysis.Results:The overall prevalence of MEC lesions and capitellum OCL was 49.9% (IR:6.7%, FG:11.7%, HT:31.5%) and 2.1%, respectively. The prevalence of IR and FG gradually increased until reaching its highest at 11-12 years of age. At 12-17 years of age, the prevalence of IR was decreased with age, whereas that of FG persisted at approximately 10% after a temporally decrease. Conversely, the prevalence of HT increased while those of IR and FG simultaneously decreased (Figure 1). Age- and position adjusted multivariable analysis revealed that the presence of MEC lesions were high risk of elbow pain, and significantly higher risk for FG (odds ratio [OR]: 4.25, 95% confidence interval [CI]: 3.23-5.62) compared to IR (OR:3.17, 95%CI:2.31-4.39) and HT (OR:2.12, 95%CI:1.76-2.55). Capitellum OCL of was also significantly high risk of elbow pain (OR:,2.69, 95%CI:1.42-5.45) (Table 1).Conclusion:Our study demonstrated that morphology of MEC apophysis in juvenile baseball player varied with age. As the presence of FG was a significantly high- risk factor for elbow pain as compared to HT, appropriate management of “Little Leaguer’s Elbow” in the preadolescent period might be quite important to accelerate the bony healing of medial epicondyle apophysitis and decrease preventable adulthood elbow pain.

Portal placement in elbow arthroscopy by novice surgeons: cadaver study.

In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined. Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured. The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22mm, p<0.001), the lateral antebrachial cutaneous nerve (4.0mm, p<0.001), and the radial nerve (25mm, p<0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32mm, p<0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration. Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30% was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

Importance of the posterior bundle of the medial ulnar collateral ligament

There has been a renewed interest in the pathomechanics of elbow dislocation, with recent literature having suggested that the medial ulnar collateral ligament is more often disrupted in dislocations than the lateral ligamentous complex. The purpose of this serial sectioning study was to determine the influence of the posterior bundle of the medial ulnar collateral ligament (pMUCL) as a stabilizer against elbow dislocation. An elbow dislocation was simulated in 5 cadaveric elbows by mechanically applying an external rotation moment and valgus force. Medial ulnohumeral joint gapping was measured at 30°, 60°, and 90° of flexion in an intact elbow after sectioning of the medial collateral ligament's anterior bundle (aMUCL) and then after sectioning of the pMUCL as well. After sectioning of the aMUCL, the pMUCL was able to stabilize the joint against dislocation. After aMUCL sectioning, the proximal joint space significantly increased by 4.2 ± 0.6 mm at 30° of flexion and 2.6 ± 0.3 mm at 60° of flexion, although it did not dislocate. The gapping increase of 0.9 ± 0.6 at 90° of flexion did not reach significance. After sectioning of the pMUCL (after having already sectioned the aMUCL), all of the specimens frankly dislocated at all flexion angles. An intact pMUCL can prevent elbow dislocation and limited joint subluxation to within 6.6 mm. Our findings indicate that repair or reconstruction may be warranted in certain circumstances (ie, residual instability after operative management of a terrible triad injury or after aMUCL reconstruction).

Medial Epicondyle Fractures in the Pediatric Overhead Athlete.

The medial epicondyle serves as the proximal attachment of the medial ulnar collateral ligament and the origin of the flexor pronator musculature and as such it is responsible for resisting the main static and dynamic restraints to valgus force at the elbow. Fractures through the physis in the developing elbow are common and treatment remains controversial. Biomechanical modeling predicts that anterior should be the direction of greatest displacement. Anatomic considerations predict that anterior displacement should have the greatest effect on elbow stability and range of motion making the ulnar collateral ligament too loose in flexion and too tight in extension and potentially leading to valgus laxity in flexion and a block to full extension. In the elite overhead athlete, where elbow stability is critical both for sports performance and the long-term health of the elbow, assessment of anterior displacement is thus theoretically an important consideration. Standard radiographic views cannot adequately assess anterior displacement. Specialized radiographs and 3-dimensional modalities such as computerized tomography and magnetic resonance imaging can adequately assess anterior displacement and in the overhead athlete can sometimes aid in the decision-making process. Here, we present a review of the current literature and the rationale for a treatment algorithm for medial epicondyle fractures in the skeletally immature overhead athlete.

Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review

Medial ulnar collateral ligament (UCL) injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction (UCLR) procedures is rapidly increasing. We sought to quantify the incidence of age-related trends for UCLR from 2003 to 2014 and subsequently to project future trends through 2025. We hypothesized that as the total number of UCLRs performed increased, a disproportionate incidence among younger patients would be observed. New York State's Statewide Planning and Research Cooperative System database was queried from 2003 to 2014 to identify individuals between 10 and 40 years old undergoing UCLR. Poisson regression was used to develop future projections for UCLR and New York State population through 2025, and incidence estimates per 100,000 people were calculated. In New York State between 2003 and 2014, there were 890 patients who underwent UCLR, with average annual incidence per 100,000 people equaling 6.3 ± 2.8 for ages 15 to 19 years, significantly greater than for all other age groups (P < .001). Projections from 2015 through 2025 suggest that incidence in 15- to 19-year-olds and 20- to 24-year-olds will continue to rapidly increase while rates for other age groups will remain relatively stable. The number of UCLRs performed between 2003 and 2014 increased by 343%, and a disproportionate trend in average annual incidence for patients between 15 and 19 years old was observed. As our review of the literature questioned outcomes in adolescent athletes after UCLR, continued attempts at preventing these injuries in the young throwing athlete remain paramount.

Kinematic Predictors of Peak Elbow Varus Moments in Adolescent Baseball Pitchers

High-magnitude elbow joint moments during overhead throwing may lead to acute or overuse injuries, especially to the medial epicondyle physis and ulnar collateral ligament (UCL). During the pitching motion, the UCL is responsible for 54% of the elbow varus moment that is required to resist valgus motion. The identification of kinematic variables that predict high-magnitude elbow varus moments in adolescent baseball pitchers is needed. PURPOSE:To develop a predictive model for peak elbow varus moments in adolescent male pitchers based on overhead throwing kinematic variables. METHODS:Ten male baseball pitchers (14.9±1.1 years; 175.7±6.7 cm; 80.5±17.9 kg) threw three fastball windup pitches while three-dimensional motion data were recorded using a 10 camera, digital motion analysis system (480 Hz). A total of 24 kinematic variables were analyzed at three temporal events occurring during the pitching motion: 1) Lead footstrike (FS), 2) Peak glenohumeral external rotation (GHER), and 3) Ball release (BR). Elbow varus joint moments were normalized to body weight and height. A multiple linear regression (MLR) using the stepwise procedure was employed to identify a predictive model for peak elbow varus moments. RESULTS:The MLR model identified five significant kinematic variables predictive of peak elbow varus moments (adj. R2=0.90, p<0.001). The model revealed that significant predictors of peak elbow varus moments included contralateral trunk lean (CTL) at FS (β=0.007, p<0.001), sagittal lead knee angle (LKA) at FS (β=-0.030, p<0.001), trunk rotation (TR) at FS (β=-0.011, p<0.001), longitudinal glove distance (LGD) at GHER (β=0.002, p=0.001) and release point distance (RPD) (β=0.011, p=0.04). Standardized β values revealed CTL at FS (β=0.699) as the strongest predictor of peak elbow varus moments, followed by LKA (β=-0.289), TR (β=-0.271), LGD (β=0.232) and RPD (β=0.139). CONCLUSIONS: Greater CTL, less flexed LKA and counter-clockwise TR at FS, greater LGD at GHER and greater RPD at BR are tendencies associated with greater elbow varus moments in adolescent male baseball pitchers. Modifying pitching mechanics may reduce excessive elbow varus moments and decrease risk of elbow injury in adolescent pitchers.

Epidemiology of Medial Ulnar Collateral Ligament Reconstruction

Background: Despite an increase in the prevalence of medial ulnar collateral ligament (UCL) reconstruction of the elbow in professional baseball and popularity within the media, there are no population-based studies examining the incidence of UCL reconstruction. Purpose: To examine the epidemiological trends of UCL reconstruction on a statewide level over a 10-year period. The primary endpoint was the yearly rate of UCL reconstruction over time; secondary endpoints included patient demographics, institution volumes, and concomitant procedures on the ulnar nerve. Study Design: Descriptive epidemiology study. Methods: The New York Statewide Planning and Research Cooperative System (SPARCS) database contains records for each ambulatory discharge in New York State. This database was used to identify all UCL reconstructions in New York State from 2002 to 2011 using the outpatient CPT-4 (Current Procedural Terminology, 4th Revision) code. Assessed were patient age, sex, ethnicity, insurance status, and associated procedures, as well as hospital volume. Results: There was a significant yearly increase in the number of UCL reconstructions (P < .001) performed in New York State from 2002 to 2011. The volume of UCL reconstructions increased by 193%, and the rate per 100,000 population tripled from 0.15 to 0.45. The mean ± SD age was 21.6 ± 8.89 years, and there was a significant trend for an increased frequency in UCL reconstruction in patients aged 17 to 18 and 19 to 20 years (P < .001). Male patients were 11.8 times more likely to have a UCL reconstruction than female patients (P < .001), and individuals with private insurance were 25 times more likely to have a UCL reconstruction than those with Medicaid (P = .0014). There was a 400% increase in concomitant ulnar nerve release/transposition performed over time in the study period, representing a significant increase in the frequency of ulnar nerve procedures at the time of UCL reconstruction (P < .001). Conclusion: The frequency of UCL reconstruction is steadily rising in New York State and becoming more common in adolescent athletes. Emphasis on public education on the risks of overuse throwing injuries and the importance of adhering to preventative guidelines is essential in youth baseball today.

Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries

Background: The medial ulnar collateral ligament (UCL) is the primary static stabilizer to valgus stress of the elbow. Injuries to the UCL are common in baseball pitchers. In the 1970s, reconstructive surgery was developed. Return-to-play (RTP) rates of 67% to 95% after reconstruction have been reported. There is a paucity of published studies among professional baseball players reporting RTP with nonoperative treatment. Purpose: To identify professional baseball players’ ability to RTP after the nonoperative treatment of UCL injuries based on the magnetic resonance imaging (MRI) grade. Study Design: Case series; Level of evidence, 4. Methods: A review of elbow injuries among a professional baseball organization from 2006 to 2011 was performed. MRI was performed on all players. Forty-three UCL injuries were diagnosed. Treatment included rehabilitation, surgery, or both. Rates of RTP and return to the same level of play or higher (RTSP) were calculated and correlated with the MRI grade, location of injury, and player position. MRI grading was as follows: I, intact ligament with or without edema; IIA, partial tear; IIB, chronic healed injury; and III, complete tear. Results: Forty-three UCL injuries in 43 players were diagnosed. Eight had complete tears (grade III), were treated operatively with UCL reconstruction, and had an RTP rate of 75% and RTSP rate of 63% (5/8 returned to the same level and 1 to a lower level). All 8 were pitchers. The remaining 35 players had incomplete injuries (4 grade I, 8 grade IIA, and 23 grade IIB), consisting of 24 pitchers and 11 positional players. Of these 35 players, 1 underwent surgery without attempted rehabilitation, 3 initiated rehabilitation until MRI was performed and then underwent surgery, and 3 underwent surgery after failed rehabilitation. The 7 players who underwent UCL reconstruction surgery had an RTP rate of 100% and RTSP rate of 86% (6/7 returned to the same level and 1 to a lower level). The remaining 28 with nonoperative treatment had both RTP and RTSP rates of 93% (26/28 returned to the same level and 0 to a lower level). Of these, 10 were positional players with an RTSP rate of 90%, and 18 were pitchers with an RTSP rate of 94%. Of all players with incomplete UCL injuries who completed nonoperative rehabilitative treatment (n = 31), 26 had a successful RTSP (84%). Conclusion: Incomplete UCL injuries in professional baseball players can be successfully treated nonoperatively in the majority of cases. Pitchers are more likely to have complete tears leading to surgery. MRI grading of UCL injuries can help predict RTP and the need for surgery.

Medial ulnar collateral ligament reconstruction of the elbow in major league baseball players: Where do we stand?

The ulnar collateral ligament (UCL) is a vital structure to the overhead athlete, especially the baseball pitcher. For reasons not completely understood, UCL injuries have become increasingly more common in major league baseball (MLB) pitchers over the past 10 years. UCL reconstruction (UCLR) is the current gold standard of treatment for these injuries in MLB pitchers who wish to return to sport (RTS) at a high level and who have failed a course of non-operative treatment. Results following UCLR in MLB pitchers have been encouraging, with multiple RTS rates now cited at greater than 80%. Unfortunately, with the rising number of UCLR, there has also been a spike in the number of revision UCLR in MLB pitchers. Similar to primary UCLR, the etiology of the increase in revision UCLR, aside from an increase in the number of pitchers who have undergone a primary UCLR, remains elusive. The current literature has attempted to address several questions including those surrounding surgical technique (method of exposure, graft choice, management of the ulnar nerve, concomitant elbow arthroscopy, etc.), post-operative rehabilitation strategies, and timing of RTS following UCLR. While some questions have been answered, many remain unknown. The literature surrounding UCLR in MLB pitchers will be reviewed, and future directions regarding this injury in these high level athletes will be discussed.

Comparison of Two Different Humeral Entries in Medial Ulnar Collateral Ligament Reconstruction Using Docking Technique in Baseball Players

Comparison of Two Different Humeral Entries in Medial Ulnar Collateral Ligament Reconstruction Using Docking Technique in Baseball Players

Media perceptions of Tommy John surgery

Objectives. The prevalence of medial ulnar collateral ligament (UCL) reconstruction is increasing in professional athletes and the delivery of baseball news by the media exerts a powerful influence on public opinion of the injury and surgery. The purpose of this investigation was to examine the media’s perception regarding the causes of UCL injury as well as the indications, risks, benefits, and rehabilitation related to UCL reconstruction. Study design. Cross-sectional survey study, Level 3. Methods. This study utilized an online thirty-question survey designed to assess an individual’s perception of UCL reconstruction with regard to risk factors for injury, indications, benefits, surgical details, and rehabilitation. Eligible study participants were members of the media including print, internet, radio and/or television directly involved in the coverage of Major League Baseball (MLB). Results. A total of 516 members of the media with a mean age of 43.6 years completed the survey. In nearly half (47.8%), professional baseball represented 76–100% of their total sports coverage responsibility. Indications: although the majority answered correctly, 45% did not know if an athlete needed an elbow injury as a prerequisite for UCL reconstruction and 25% believed the primary indication was performance enhancement. As percentage of baseball coverage increased, media members were less likely to believe that an elbow injury was not required (p = 0.038). Benefits: eighty percent recognized that pitching speed is typically reduced following surgery, but the remaining 20% felt that velocities actually increased compared with pre-injury velocities. Return to play: fifty-two percent overestimated the ability of pitchers to return to back to professional baseball and 51.2% believed return would occur in 12 or less months. Estimates were higher in those of older age (p = 0.032) and increased percentage of baseball coverage (p < 0.001). Overuse injuries: less than half (48.4%) believed the use of pitch counts to be important in the prevention of UCL injury and 33.2% felt that throwing injuries were not preventable in adolescent baseball. Conclusion. Common misconceptions exist regarding UCL reconstruction within the professional baseball media. Efforts for physicians to educate the media on the risks of overuse throwing injuries with emphasis on accurate indications, outcomes, and recovery of Tommy John Surgery are encouraged.

United States Trends in Medial Ulnar Collateral Ligament Reconstruction: A retrospective Review of a Large Private-Payer Database from 2007 to 2011

Objectives:Purpose: Overuse injuries to the elbow in the throwing athlete are common. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on both recreational and high-level athletes. There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to age, location within the Unites States (U.S.), and gender. The purpose of this study is to determine the current demographic distribution of UCLR within the U.S.Methods:Methods: A retrospective analysis of private payer database using the PearlDiver Supercomputer (Warsaw, IN) was performed to identify UCLR procedures performed between the years of 2007-2011. The Current Procedural Code (CPT) 24346 (reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft) was used. Statistical analysis was performed as appropriate using STATA (Version 12.1; Statacorp; College Station, TX, USA).Results:Results: Between 2007-2011, 790 patients underwent UCLR. The overall average annual incidence was 2.16+/- 0.27 per 100,000 patients, but was 31.9 +/-3.9 for patients aged 15-19. The average annual growth was 5.72%. There were 695 males and 95 females. Fifteen to 19 year olds accounted for significantly more procedures than any other age group 56.8% (p<0.001), followed by 20 to 24 year olds 23.4%. The incidence of UCLR in the 15-19 year old group increased at an average rate of 6% per year (incidence rate ratio = 1.06, p=0.025). The south region performed significantly more UCLR than any other region p<0.001. The number of procedures significantly increased over time (p=0.039).Conclusion:Conclusion: UCLR was performed significantly more in patients aged 15-19 than any other age group. The average annual incidence of UCLR per 100,000 people for patients aged 15-19 is 31.9. The number of UCLR is increasing over time. Further work should address risk-reduction efforts in this at-risk population.