Primary Ulnar Collateral Ligament Research Articles

Favorable Outcomes Following Elbow Ulnar Collateral Ligament Reconstruction and Repair, Though Repair Associated with Increased Risk of Revision Surgery

To assess the risk of revision surgery following repair versus reconstruction of the medial ulnar collateral ligament (UCL) of the elbow in a national sample of patients in the United States. This was a retrospective cohort study of young patients (≤35 years old) who underwent primary UCL reconstruction or repair for an isolated medial UCL injury of the elbow from October 2015 through October 2022 in a large national database (PearlDiver). Patient demographic data, comorbidities, surgical details, and concomitant ulnar nerve procedures were collected. Time-to-event analyses were used to assess the risk of revision UCL surgery between groups. Two-year complication rates, including ulnar neuropathy, were also assessed. In total, 1,820 patients (69.9% reconstruction, 30.1% repair) with an average follow-up of 2.9 years met inclusion criteria. The estimated 2-year revision-free survival (95% confidence interval) was 99.5% (99.1%-99.9%) for UCL reconstruction compared to 97.9% (96.4%-99.3%) for UCL repair (unadjusted log-rank P= .032). UCL repair remained associated with an increased risk of revision UCL surgery after adjusting for confounding variables (hazard ratio, 2.94; 95% confidence interval, 1.07-8.09; P= .037). Complication rates were similar between reconstruction and repair, including the incidence of ulnar neuropathy (13.8% vs 14.5%, P= .78). In this study, we found that UCL repair was associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample. Importantly, however, overall failure rates were low, and complication rates were similar between procedures. These findings support the overall favorable outcomes of UCL repair while suggesting it may not necessarily be the optimal treatment for all patients. Level III, retrospective cohort study.

Poster 169: Preliminary Outcomes of Revision UCL Repair With Suture Tape Augmentation for Failure of Primary UCL Reconstruction in Professional and Collegiate Pitchers

Objectives: Injury of the ulnar collateral ligament (UCL) is common in baseball players and pitchers, in particular. The gold standard surgical treatment has been UCL reconstruction with autograft, although, UCL repair with collagen-coated suture tape has shown promise as an alternative recently. The outcomes of UCL reconstruction and UCL repair are well-studied, demonstrating high rates of return to sport and a predictable postoperative course of recovery. However, revision UCL reconstructions with allografts do not demonstrate comparable outcomes when compared with primary procedures. This pilot case series reports on the preliminary outcomes of collegiate and professional pitchers who underwent revision UCL repair with collagen-coated suture tape following failure of primary UCL reconstruction. Methods: We performed a retrospective query of a prospectively collected data repository to identify patients at our institution who had undergone UCL repair with internal brace. Additional inclusion criteria included: 1) prior failed UCL reconstruction with autograft; 2) aged between 15 and 45 years; 3) at least 1-year post-operative. From the included cohort, we collected demographic, clinical, and surgical data from the electronic health record. We further collected patient-reported outcomes data using either a web-based database platform or via telephone, including the American Shoulder and Elbow Surgeons Elbow assessment form (ASES-E; satisfaction, pain, and function subscales), the Kerlan Jobe Orthopaedic Clinic Shoulder and Elbow score (KJOC), Andrews Carson score, and information on return-to-sport timing and success. To evaluate outcomes, we reported the proportions of athletes that were able to successfully return-to-sport at the preinjury level or higher as well as return-to-sport timing and level of competition. Additionally, we reported summary statistics for patient-reported questionnaires evaluated at follow-up (ASES-E, KJOC, and Andrews Carson). Results: A total of 10 patients met inclusion criteria, and all were professional or collegiate pitchers at the time of their revision UCL repair surgery (40% professional and 60% collegiate). The mean follow-up time was 3.0 years (Table 1; range: 1-5 years). Table 1 shows complete return-to-sport data. All patients were able to return-to-sport at the same or higher level, and the mean time from surgery to return-to-sport was 9.3 months. Table 2 shows complete patient-reported outcomes data. Mean scores on elbow-related function questionnaires were high (ASES-E Function = 35.8 out of a maximum best of 36; KJOC = 88.3 out of a maximum best of 100; Andrews Carson = 94.5 out of a maximum best of 100) and mean pain scores were low (ASES-E Pain = 1 out of a maximum worst score of 50). Conclusions: This pilot case series demonstrated promising results of a novel UCL repair approach utilizing collagen-coated suture tape for high-level pitchers with recurrent medial elbow instability following initial UCL reconstruction with autograft. Specifically, we found excellent return-to-sport success and patient-reported outcomes in this preliminary cohort. Further study is warranted with larger sample sizes to further evaluate outcomes following revision of UCL reconstruction with UCL repair utilizing internal bracing.

Ulnar collateral ligament repair in professional baseball players.

While initial reports of surgical repair of ulnar collateral ligament tears are promising, studies detailing post-repair outcomes are lacking. This study explores the effectiveness of ulnar collateral ligament (UCL) repair in returning professional baseball players to their pre-injury level of play. Our hypothesis is that professional baseball players undergoing UCL repair will have successful outcomes and high return to sport rates after surgery. Publicly available databases were utilized to search for data on professional baseball players who underwent UCL repair from 2016 to 2021. Players undergoing primary UCL repair with an internal brace were included. Amateur players were excluded as were those undergoing revision UCL repair or UCL reconstruction. Of the 11 pitchers who underwent UCL repair, minor league baseball (MiLB) pitchers returned to the sport at an average of 17.5 months. MiLB pitchers had similar earned run averages (ERAs), games played, innings pitched, and walks plus hits per inning pitched ratios (WHIPs) before and after surgery. Four major league baseball (MLB) pitchers (80%) returned to the sport at 9.55 months. MLB pitchers played fewer games and pitched fewer innings than before the surgery, but their ERAs and WHIPs were similar before and after surgery. Pitch velocity and spin rates after surgery varied based on pitch type. The seven positional players who underwent UCL repair showed no differences in batting or fielding performance before and after surgery. UCL repair can successfully return both pitchers and positional players at both the MiLB and MLB levels to play at pre-injury performance levels. Repair can be considered as an option for qualifying injuries in players hoping to maximize performance after surgery with minimal recovery time. Level of Evidence: IV.

Augmented Ulnar Collateral Ligament Repair With Structural Bioinductive Scaffold: A Biomechanical Study

Background: Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair. Purpose/Hypothesis: This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening. Study Design: Controlled laboratory study. Methods: Eight cadaveric elbow specimens—from midforearm to midhumerus—were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL—with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected—distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing. Results: The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold–augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first. Conclusion: UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted. Clinical Relevance: As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.

Operative Treatment of Ulnar Collateral Ligament Injury in Female Athletes.

Ulnar collateral ligament (UCL) reconstruction has been the standard surgical intervention for elite male athletes with UCL insufficiency. Recently, UCL repair and augmentation with an internal brace has been increasingly performed. To evaluate the clinical and functional outcomes as well as return-to-sport rate after UCL repair in female athletes. Case series; Level of evidence, 4. Included were 15 female athletes (mean age, 16.5 ± 3.5 years) who underwent UCL repair between 2011 and 2021 at a single institution. Data collected included age, sport played, competition level, symptom onset, previous surgeries, mechanism of injury, surgical intervention, and return to sport. Patients were contacted via phone at minimum 24-month follow-up, and postoperative outcomes were evaluated using the Mayo Elbow Performance Score (MEPS) and the Single Assessment Numeric Evaluation (SANE). Of the 15 female athletes, there were 4 cheerleaders, 3 softball players, 2 volleyball players, 2 soccer players, 1 gymnast, 1 tennis player, 1 dancer, and 1 javelin thrower. Ten of the 15 athletes (67%) competed at the high school level, 4 (26%) at the collegiate level, and 1 patient (7%) was a recreational volleyball player. In all patients, there was an acute onset of symptoms after injury. Ten patients underwent UCL repair with an internal brace (67% of athletes), while 5 underwent standard UCL repair. The median MEPS for athletes with and without an internal brace was 100 (range, 80-100). There was no significant difference of MEPS (P = .826) or SANE scores (P = .189) between the patients who received an internal brace and those who did not. Thirteen of the 15 athletes (86.7%) returned to sport. The UCL injuries in the female athletes in this study were the result of acute trauma. Primary UCL repair, both with and without internal bracing, was an effective surgical treatment for returning these athletes to sport.

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]

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.

Does Prehabilitation Before Surgery Affect Return to Sport in Baseball Pitchers With Partial Ulnar Collateral Ligament Tears?

Purposeful rehabilitation before surgery (prehabilitation) has been researched and implemented in the treatment of anterior cruciate ligament tears. However, it is unclear whether prehabilitation would affect outcomes for baseball pitchers with partial ulnar collateral ligament (UCL) tears. The purpose of this study was to determine whether baseball pitchers with partial UCL tears who completed ≥4 weeks of prehabilitation (prehab group) have different return to play (RTP) outcomes than pitchers with 0 to 3 weeks of preoperative physical therapy (no prehab group). We hypothesized that pitchers in the prehab group would have similar RTP rates compared with pitchers in the no prehab group. Cohort study; Level of evidence, 3. Baseball pitchers of all competitive levels who underwent primary UCL reconstruction (UCLR) or UCL repair between 2010 and 2019 were included. Physician chart notes, magnetic resonance images, and operative notes were screened to confirm primary UCLR or UCL repair of a partial UCL tear and to identify whether the nonoperative treatment had been attempted. Patients were contacted via RedCap for postoperative complications, reoperations, RTP, and patient-reported outcomes (Kerlan-Jobe Orthopaedic Clinic score, Andrews-Timmerman score, Conway-Jobe score, and satisfaction). Overall, 105 baseball pitchers (n = 55 prehab group; n = 50 no prehab group) were included and evaluated at 3.4 ± 2.5 years postoperatively. Six pitchers underwent UCL repair, and 99 pitchers underwent UCLR. All demographic characteristics were similar between groups except the prehab group received a gracilis graft more frequently (76.5% vs 51.2%; P = .038). The RTP rate (prehab [88.1%] vs no prehab [93.8%]; P = .465) was similar between groups. All other postoperative outcomes were also similar between groups, including revision rates and patient-reported outcomes. Postoperative and patient-reported outcomes did not differ significantly between pitchers with partial UCL tears who performed rehabilitation before UCL surgery and pitchers who did not attempt a significant period of rehabilitation before UCL surgery. Clinicians should feel comfortable recommending rehabilitation for patients with partial UCL tears who wish to attempt a period of nonoperative treatment, as postoperative outcomes are not affected if UCL surgery is later needed.

Pain Is the Most Frequently Cited Reason Athletes Fail to Return to Sport After Ulnar Collateral Ligament Surgery: A Systematic Review and Meta-analysis.

Background:No previous systematic review to our knowledge has examined the reasons that athletes fail to return to sport (RTS) after ulnar collateral ligament (UCL) surgery.Purpose:To report the rate of failure to RTS after UCL surgery and identify reasons that preclude an athlete’s ability to successfully RTS.Study Design:Systematic review; Level of evidence, 4.Methods:This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Scopus, and SPORTDiscus databases for studies on athletes who underwent either UCL reconstruction or repair that reported RTS rates and identified reasons for failure to RTS. Data were collected on the number of athletes included, average age, sport played, operative technique, average follow-up, rate of failure to RTS, and reasons for failure to return. A random-effects model was used to conduct the meta-analysis.Results:Included were 26 studies reporting on 1019 athletes. Primary or revision UCL reconstruction was performed in 913 patients (89.6%), while the remaining 106 patients (10.4%) underwent UCL repair. The pooled rate of failure to RTS after UCL reconstruction or repair was calculated to be 11.4% (95% CI, 8.4-14.7). A significantly higher estimated proportion of athletes failed to return because of elbow-related reasons compared with non–elbow-related reasons (55.3% vs 40.6%; P = .0352). Persistent pain (29/103; 28.2%) was the most common reason for failure to return, followed by elbow limitations and other unspecified elbow problems (19/103; 18.4%). There was moderate evidence for publication bias and study heterogeneity across the included studies.Conclusion:This meta-analysis estimated the rate of failure to RTS after UCL surgery as 11.4%, with the majority of athletes unable to return because of elbow pain. Future studies reporting outcomes and providing details as to why athletes are unable to RTS can better inform sport surgeons on factors precluding RTS and can guide clinical practice to better help athletes achieve their postoperative goals.

Return-to-Sport Outcomes After Primary Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Tendon Grafts: A Systematic Review.

Background:Ulnar collateral ligament (UCL) reconstruction is the current gold standard of treatment for overhead athletes with a symptomatic, deficient UCL of the elbow who have failed nonoperative treatment and wish to return to sport (RTS) at a high level. The palmaris longus and hamstring tendons are common graft choices, but no study has analyzed the existing literature to assess whether one graft is superior to the other.Purpose:To systematically report on the outcomes of UCL reconstruction using palmaris and hamstring autografts.Study Design:Systematic review; Level of evidence, 4.Methods:A combination of the terms “ulnar collateral ligament,” “valgus instability,” “Tommy John surgery,” “hamstring,” and “palmaris longus” were searched in PubMed, Embase, and the Cochrane Library. RTS and return-to-same-level (RSL) rates, patient-reported outcomes, and complications were included for analysis. We used the modified Coleman Methodology Score and risk-of-bias tool for nonrandomized studies to assess the quality of the included studies.Results:This review included 6 studies (combined total of 2154 elbows) that directly compared palmaris and hamstring graft use in UCL reconstruction. Follow-up ranged from 24 to 80.4 months, and the mean patient age across all studies was 21.8 years. The mean RSL across all studies and grafts was 79.0%, and the mean RTS was 84.1%, consistent with results previously reported in the literature. The mean RTS and RSL rates for the palmaris graft group were 84.6% and 82%, respectively; the hamstring graft group showed mean RTS and RSL rates of 80.8% and 80.8%. Meta-analysis revealed no significant difference in RSL between the 2 graft groups (odds ratio, 1.06; 95% CI, 0.77-1.46). The combined complication rate of the included studies was 18.2%, with failure rates ranging from 0% to 7.1%.Conclusion:Results of this review indicated that both palmaris and hamstring tendon grafts are viable options for primary UCL reconstruction. Graft choice should be determined by a combination of patient and surgeon preference.

Performance Analytics and Pitch Metrics as Predictors of Ulnar Collateral Ligament Injury in Major League Baseball Pitchers (128)

Objectives:Ulnar collateral ligament (UCL) injury is a significant concern in elite throwers, and it is associated with prolonged time away from competition in Major League Baseball (MLB) pitchers. Identifying athletes at higher risk of injury, with the subsequent goal of injury prevention, may positively impact pitcher health while mitigating the significant economic impact of this injury on professional organizations. As technology continues to advance, more granular assessments of performance are becoming possible. In 2015, Major League Baseball introduced StatCast, a spatiotemporal data tracking system that uses a standardized camera system and radar technology, to optically track player and ball movement to measure and quantify game events. This technology allows for further investigation of the science of pitching and provides new frontiers for injury research. Understanding UCL injuries in MLB pitchers may also provide insight into youth pitching injuries. To date, there is a paucity of evidence regarding risk factors of UCL injury in MLB pitchers.Methods:All MLB pitchers who underwent primary UCLR between 2015 and 2019 were identified from publicly available reports. This date range was selected to capture the seasons in which Statcast data was available. Advanced analytics and pitch metrics from the injury season—including velocity, spin rates, and pitch movement from MLB StatCast data—were collected as well as the seasonal data of an uninjured control group. Binomial logistic regression analysis was performed to determine risk factors for UCL injury.Results:Seventy-six MLB pitchers undergoing primary UCL reconstruction were included, and a control group of 95 uninjured pitchers was identified. There was no significant difference in age, height, weight, or BMI between the two cohorts. A logistic regression model was created using the following variables: 4-seam fastball velocity, 4-seam fastball spin rate, slider spin rate, curveball spin rate, strikeout percentage, and wins above replacement (WAR). The model explained 18.4% of the variance and predicted 70.4% of UCL injuries. Increasing WAR was associated with increasing likelihood of subsequent UCL injury (odds ratio [OR] 2.34; 95% CI, 1.08–5.07; p = 0.031).Conclusions:When controlling for fastball velocity and pitch spin rates, MLB pitchers who are more valuable, as indicated by WAR, may be at an elevated risk of UCL injury. While velocity is a known risk factor for UCL injury, this model indicates that other factors, including performance or pitch metrics, may influence single-season injury risk and warrant future investigation in multi-year studies.

Preventing Tommy John Surgery: The Identification of Trends in Pitch Selection, Velocity, and Spin Rate Before Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

Background:Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured.Purpose:To determine if there is a patterned change in MLB pitchers’ pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or –1 signifying a stronger monotonic trend.Results:A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = –0.657; P < .001), 2-seam fastballs (τb = –0.429; P = .029), and sliders (τb = –0.524; P = .008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P = .038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = –0.581; P = .003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P = .013).Conclusion:The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes.

Biomechanical assessment of docking ulnar collateral ligament reconstruction after failed ulnar collateral ligament repair with suture augmentation

Ulnar collateral ligament (UCL) repair with single-strand suture augmentation has been introduced as a viable surgical option for throwers with acute UCL tears. For the original single-strand suture augmentation construct, revision UCL reconstructions can be challenging owing to the bone loss at the site of anchor insertion in the center of the sublime tubercle. This biomechanical study assessed a small-diameter (1.5-mm) ulnar bone tunnel technique for double-strand suture-augmented UCL repair that may be more easily converted to salvage UCL reconstruction if necessary, as well as a salvage UCL reconstruction with a docking technique after a failed primary suture-augmented UCL repair. In 7 fresh-frozen cadaveric upper extremities (mean age, 66.3 years), a custom shoulder testing system was used to simulate the late cocking phase of throwing. The elbow valgus opening angle was evaluated using a MicroScribe 3DLX device for sequentially increasing valgus torque (from 0.75 to 7.5 Nm in 0.75-Nm increments) at 90° of flexion. Valgus angular stiffness (in newton-meters per degree) was defined as the correlation of sequentially increasing valgus torque with the valgus opening angle through simple linear regression (slope of valgus torque - valgus opening angle curve). Four conditions were tested: intact elbow, distal UCL avulsion, primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels, and subsequent docking UCL reconstruction in the same specimen. Load-to-failure tests were performed for primary UCL repair with double-strand suture augmentation and subsequent docking UCL reconstruction. With increasing elbow valgus torque, the valgus opening angle increased linearly in each condition (R2 ≥ 0.98, P < .001). Distal UCL avulsion resulted in significantly decreased angular stiffness compared with the intact UCL (P < .001). Both UCL repair with double-strand suture augmentation and subsequent UCL reconstruction showed significantly increased angular stiffness values compared with distal UCL avulsion (P < .001 and P < .001, respectively). On load-to-failure testing, there was no significant difference in stiffness, yield torque, and ultimate torque between the primary suture-augmented UCL repair and the subsequent UCL reconstruction (P = .11, P = .77, and P = .38, respectively). In all specimens undergoing the small-diameter ulnar bone tunnel technique for double-strand suture-augmented UCL repair, failure occurred by retear of the repaired ligament without causing an ulnar bone bridge fracture. Primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels was able to restore valgus stability. When failure occurs, this technique retains enough cortical bone to permit subsequent docking UCL reconstruction.

Return to Play in Athletes After Thumb Ulnar Collateral Ligament Repair With Suture Tape Augmentation.

Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. These tears often occur as a result of a radially directed force on an extended thumb. To date, no literature exists on the use of suture tape augmentation for repair of the thumb UCL in a competitive athlete cohort.Hypothesis:Using suture tape augmentation for the thumb UCL will allow for a safe and expedient return to play in competitive athletes.Study Design:Case series; Level of evidence, 4.Methods:A retrospective chart review was completed to identify all patients who underwent operative primary thumb UCL repair between 2014 and 2018. All procedures were performed at a single institution by the senior author. Inclusion criteria were acute complete tears of the thumb metacarpophalangeal joint UCL, treated with primary repair via suture tape augmentation in competitive high school, collegiate, or professional athletes. Exclusion criteria included recreational athletes, patients who underwent reconstruction (rather than repair), and patients with insufficient follow-up to establish return to play. Charts of patients identified through the retrospective review were further evaluated to determine patient- and injury-related variables. Return to play was defined as return to game competition and stratified as to whether this was at the same level of competition or any level of competition.Results:A total of 18 thumbs in 17 competitive high school, collegiate, and professional athletes were included in this study. One of the professional basketball players sustained injury to both thumbs approximately 10 months apart. The study group comprised 4 collegiate baseball players, 6 professional baseball players, 3 professional basketball players, 1 professional hockey player, 1 amateur-level hockey player, 1 high school basketball player, and 1 high school volleyball player. Mean follow-up was 27.9 months, and no complications were noted. Athletes who sustained an in-season injury (n = 13; 72.2%) returned to play at any level at a mean ± SD of 30.9 ± 10.1 days and at the same level at 36.3 ± 11.2 days. Athletes who sustained an out-of-season injury (n = 5; 27.8%) returned to play at any level at 101.4 ± 86.6 days and at the same level at 114.6 ± 87.0 days.Conclusion:The findings presented here offer evidence for return to play in competitive high school, collegiate, and professional athletes with a thumb UCL tear treated with repair and suture tape augmentation. All athletes returned to the same level of play. Those attempting to return in-season returned to the same level of play at a mean of just under 5 weeks. Augmenting the repair with anchored suture may prevent prolonged immobilization, expedite thumb motion, and improve postoperative recovery.

A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players

BackgroundThe rate of ulnar collateral ligament (UCL) reconstruction has been increasing at all levels of play. With excellent outcomes, primary UCL reconstruction has allowed many overhead athletes to return to their pre-injury sport. However, the subjective factors influencing this decision to return to sport have yet to be studied. The aim of this study is to understand the factors influencing an athlete's decision to return to pre-injury level of sport after primary UCL reconstruction. MethodsAn experienced interviewer conducted qualitative, semi-structured interviews of patients aged 18–35 years who had undergone primary UCL reconstruction by one fellowship-trained, Major League Baseball (MLB) team orthopaedic surgeon. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Qualitative analysis was then performed to derive codes, categories, and themes. Patients were surveyed to assess familiarity with UCL reconstruction as well as to obtain Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) highlighting current activity and function levels along with sport participation. ResultsTwenty-two athletes were interviewed to elucidate four predominant themes influencing their return to sport: trust in surgeon and care team, innate drive and optimism, misconceptions regarding post-operative athletic ability, and life priorities. A significant difference was noted between patients that returned and those that did not in the KJOC survey and for the statement that UCL reconstruction surgery would improve throwing ability relative to patients’ peak performance three years prior to the surgery. Athletes who did not return to sport cited lifestyle changes and age as limiting factors. ConclusionPatients' decision to return to their pre-injury level of sport after primary UCL reconstruction was based on trust in their care team's reputation, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and lifestyle. This study emphasizes the importance for health care providers to educate patients toward realistic expectations upon return to sport. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport. Level of evidenceLevel IV.

Outcomes With a Focus on Return to Play for Revision Ulnar Collateral Ligament Surgery Among Elite-Level Baseball Players: A Systematic Review

Background: Ulnar collateral ligament (UCL) reconstruction is commonly performed among overhead throwing athletes. Previous studies demonstrated relatively high rates of return to sport after primary reconstruction. Outcomes after revision UCL reconstruction have not been widely studied. Purpose: To report the rate of return to sport after revision UCL reconstruction among elite-level baseball players. Study Design: Systematic review. Methods: A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed for high-level baseball players undergoing revision UCL reconstruction. Study bias was assessed with the Methodological Index for Non-Randomized Studies scoring system. The primary outcome measure was whether the study participants were able to return to sport after revision UCL reconstruction. Secondary outcome measures included career length after revision and pitching performance statistics. Data were summarized with ranges, tables, and weighted averages. A subjective analysis was performed. Results: A total of 5 studies met inclusion criteria. The rate of return to sport at preinjury level was 62.8%. Among Major League Baseball pitchers, the rate of return to sport at the preinjury level was 68.8%. The rate of return to sport at the same level or lower (Major League Baseball, minor league, collegiate) was 78.1%. Time to return to sport ranged from 1.3 to 1.7 years. Mean earned run average after revision ranged from 4.87 to 5.04. Mean number of innings pitched per season after revision ranged from 36.95 to 50.5. Conclusion: This systematic review demonstrated a limited rate of return to preinjury level of sport among elite-level baseball players who underwent revision UCL reconstruction. Pitching durability and career longevity were inferior to results that were reported for players who underwent primary UCL reconstruction alone. This study suggests that outcomes after revision UCL reconstruction are not reliable and elite-level players should be counseled accordingly.

Epidemiology of ulnar collateral ligament reconstruction in Major and Minor League Baseball pitchers: comprehensive report of 1429 cases

The primary purpose of this work is to provide an epidemiologic report on every known ulnar collateral ligament (UCL) reconstruction performed in professional baseball with a special focus on outcomes and survivorship. Three resources, including the Major League Baseball (MLB) injury tracking system, were combined and cross-referenced to identify all known professional baseball pitchers who had ever undergone UCL reconstruction from 1974 to 2016. Variables analyzed included injury date, surgery date, return to play rates, time out of play, and revision status. Trends over time were analyzed collectively and by level of play at the time of surgery. A minimum of 2 years of follow-up was required for return to play analysis. We identified 1429 UCL reconstructions. The annual rate of primary and revision UCL reconstructions rose significantly (P < .001). Most players (83.7%) returned to any level of play at a mean of 435 days, whereas 72.8% (P < .001) returned to their prior level at a mean of 506 days. Major League Baseball players were more likely than Minor League Baseball players to return to any level (94.6% vs. 79.0%, P < .001) and their prior level of performance (80.0% vs. 69.1%, P = .04). The mean overall survivorship free from revision and still playing was 3.8 years (3.9 for primary vs. 2.9 for revisions, P = .018). The revision rate was 6.7% and was higher for Major League Baseball (9.4%) vs. Minor League Baseball (5.2%, P = .004). This study represents the most robust epidemiologic report of UCL reconstruction in baseball to date, and a multitude of novel findings are reported.

Following ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequently

Although much as been done to characterize trends of medial ulnar collateral ligament (UCL) reconstruction in pitchers, outcomes in position players (PPs) (non-pitchers) remain undefined in the current literature. Three resources were combined to identify all known Major League Baseball and Minor League Baseball (MiLB) PPs who have ever undergone UCL reconstruction. A multitude of player and surgical variables were included. Trends over time were analyzed collectively, based on level of play, revision status (primary vs revision), and position. Additional comparisons were made with a known cohort of professional baseball pitchers having undergone UCL reconstruction. We identified 168 UCL reconstructions in professional PPs. The annual rate of primary UCL reconstruction rose significantly from 1984 to 2015 (P < .001), and the proportion of cases performed in MiLB PPs (vs Major League Baseball PPs) increased steadily (P < .001). Of PPs, 75.5% returned to play at any level at a mean of 342 days. Catchers demonstrated the lowest return-to-play (RTP) rate (58.6%) compared with infielders (75.6%) and outfielders (88.9%). The overall revision rate was low, at 4.8%. Compared with pitchers, PPs demonstrated a lower rate of RTP (75.5% for PPs vs 83.7% for pitchers, P = .040) but shorter RTP times for those able to return (342 days for PPs vs 435 days for pitchers, P < .001). The incidence of UCL reconstruction in PPs continues to rise, a trend that is significantly more pronounced at the MiLB level. Although PPs (particularly catchers) are less likely to return to professional baseball compared with pitchers, those who are able to RTP do so more rapidly.

Prevalence and clinical outcomes of heterotopic ossification after ulnar collateral ligament reconstruction

Ulnar collateral ligament (UCL) reconstruction has become increasingly popular in elite athletes. However, the prevalence of heterotopic ossification (HO) formation after UCL reconstruction has not yet been reported. We sought to determine the prevalence of HO formation after UCL reconstruction and the clinical outcomes following HO treatment. From October 2005 to April 2014, 179 patients underwent primary UCL reconstruction. Of the 179 patients, 161 with a minimum of 2 years of follow-up were retrospectively reviewed to evaluate HO formation and clinical outcomes. Among 161 patients, HO was detected in 8 cases (5%). Of these 8 patients, 2 were asymptomatic and another 2 complained about transient ulnar neuropathy. The remaining 4 patients had pain; 2 were treated with open excision, and 1 underwent arthroscopic excision. The odds of HO in patients in whom transient ulnar neuropathy develops after UCL reconstruction are 6 times higher than those without transient ulnar neuropathy (odds ratio, 5.957; 95% confidence level, P = .04). Of the 8 patients, 7 returned to the same level or a higher level of competition. HO was found, on average, 5 months (range, 3-9 months) after UCL reconstruction. The prevalence of HO formation was approximately 5% after UCL reconstruction and increased with transient ulnar neuropathy. After UCL reconstruction, the surgeon should carefully observe HO formation, especially in the early stages after the operation. With appropriate treatment, the clinical outcomes of HO treatment after UCL reconstruction are favorable.

Major League pitching workload after primary ulnar collateral ligament reconstruction and risk for revision surgery

Literature has attempted to correlate pitching workload with risk of ulnar collateral ligament (UCL) injury; however, limited data are available in evaluating workload and its relationship with the need for revision reconstruction in Major League Baseball (MLB) pitchers. We identified 29 MLB pitchers who underwent primary UCL reconstruction surgery and subsequently required revision reconstruction and compared them with 121 MLB pitchers who underwent primary reconstruction but did not later require revision surgery. Games pitched, pitch counts, and innings pitched were evaluated and compared for the seasons after returning from primary reconstruction and for the last season pitched before undergoing revision surgery. The difference in workload between pitchers who did and did not require revision reconstruction was not statistically significant in games pitched, innings pitched, and MLB-only pitch counts. The one significant difference in workload was in total pitch counts (combined MLB and minor league), with the pitchers who required revision surgery pitching less than those who did not (primary: 1413.6 pitches vs. revision: 959.0 pitches, P = .04). In addition, pitchers who required revision surgery underwent primary reconstruction at an early age (22.9 years vs. 27.3 years, P < .001) and had less MLB experience (1.5 years vs. 5.0 years, P < .001). There is no specific number of pitches, innings, or games that place a pitcher at an increase risk for injury after primary UCL reconstruction. However, correlations of risk may be younger age and less MLB experience at the time of the primary reconstruction.