Ulnar Collateral Ligament Reconstruction Research Articles

Paper 23: Outcomes Following Arthroscopic Removal of A Posteromedial Osteophyte and Risk of Future Ulnar Collateral Ligament Reconstruction

Objectives: Despite successful return to sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of removing this osteophyte is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who have an isolated posteromedial osteophyte resection progress to require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophyte in overhead athletes and determine if baseball pitchers who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. Methods: All patients who underwent elbow arthroscopy from 2010-2020 were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms and had no history of prior elbow surgery. Primary outcomes included RTS rate, complications, subsequent shoulder and elbow injury/surgery and several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews Elbow score, Conway-Jobe score). Results: Overall, 36 overhead athletes were evaluated at 5.1 years post-operatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. 77% of overhead athletes RTS and had a mean KJOC score of 70, with 89% of athletes having either an excellent (73%) or good (16%) Conway-Jobe score at long-term follow-up. Subsequent UCLR was required in 18% (n=5) of baseball pitchers at a median of 13 months post-op. Three of the five UCLR were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months post-op), while the other two UCLRs were performed at 6.2 and 7.5 years post-op. Conclusions: Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic posteromedial osteophyte resection have an 18% risk of subsequent UCLR.

Ulnar Collateral Ligament Reconstruction with Hamstring Autograft

Background: Ulnar collateral ligament (UCL) reconstructions have become increasingly common, particularly in youth overhead throwing athletes. These injuries are most commonly due to overuse and repetitive trauma on the inner elbow. Throwers with a deficient UCL often report decreased pitching speeds in addition to elbow pain and instability. Indication: The indications for this procedure include symptomatic valgus elbow instability during overhead throwing motions and a verified rupture of the UCL on advanced imaging. Technique Description: The ipsilateral gracilis tendon is harvested and prepared as an autograft. A 5-cm incision is then made centered over the medial epicondyle. The ulnar nerve is identified and neurolysis is performed both proximally and distally. The fascia overlying the flexor carpi ulnaris is incised, and the two heads of the muscle are split. From this base, the sublime tubercle is identified, and the UCL is opened longitudinally in line with its fibers. A standard guide is used to drill holes in the posterior and anterior aspects of the sublime tubercle. These holes are then connected using a curved curette, and a suture is passed along the tunnels for later graft passage. A 15-mm blind-end tunnel is drilled two-thirds from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with K-wires to pass sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is then passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is then undertaken so that both ends are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the two limbs of the graft are sutured together to appropriately tension the graft. Results: In our experience, 94% of athletes return to previous levels of play and experience high patient-reported outcome scores. Discussion/Conclusion: Advancements in UCL reconstruction techniques and our understanding of elbow anatomy should prompt surgeons to continue considering this treatment for patients with significant throwing pain and a strong desire to return to high levels of throwing. 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.

Systematic Assessment of the Quality and Comprehensibility of YouTube Content on Ulnar Collateral Ligament Injury and Management.

Ulnar collateral ligament (UCL) reconstruction has received a unique level of attention in the press and social media. There has also been an increasing use of the internet by patients to seek medical information. Concern exists regarding the quality and comprehensibility of online information when used for patient education. To evaluate the quality and comprehensibility of the most-viewed YouTube videos related to the diagnosis and management of UCL injuries. Based on our new evidence-based scoring rubrics, we hypothesized that the quality and comprehensibility of these videos would be poor. Cross-sectional study. The YouTube platform was searched on September 7, 2021, with the terms "UCL injury," "ulnar collateral ligament injury," "UCL surgery," "ulnar collateral ligament surgery," and "Tommy John surgery," and the 50 most-viewed videos from each search were compiled, yielding 250 videos. After removal of duplicates and application of exclusion criteria, the 100 most-viewed videos remained. Basic attributes, including duration of video and number of views, were recorded. Each video was then analyzed by 2 independent reviewers and evaluated for 4 key parameters (quality of diagnostic content [QAR-D], quality of treatment content [QAR-T], presence of inaccurate information, and comprehensibility) and graded on a novel scale from 1 to 4 (4 being the most appropriate for patient education). The mean QAR-D was 4.83 ± 3.41 (fair quality), and the mean QAR-T was 2.76 ± 3.26 (poor quality). Physician-led educational videos had both the highest mean QAR-D (6.37) and the highest mean QAR-T (4.34). No correlation was observed between video quality and views/likes. A total of 12 videos included ≥1 inaccuracy. The mean comprehensibility score was 2.66 ± 1.12, with 39 videos falling below the acceptable comprehensibility threshold (score <3). The overall quality of UCL injury-related YouTube content was low. In addition, the absence of correlation between video quality and views/likes suggests that patients are not preferentially utilizing the limited high-quality content that does exist on the YouTube platform. In addition, inaccurate videos were prevalent (12%), and almost half of all videos were deemed inappropriate for patient education in terms of comprehensibility, as defined by our comprehensibility parameter.

Clinical Outcomes After Ulnar Collateral Ligament Reconstructions With Concomitant Ulnar Nerve Transposition in Overhead Athletes: A Matched Cohort Analysis

Background: Injury of the ulnar collateral ligament (UCL) has become increasingly common, particularly in overhead athletes. There is no consensus on management of the ulnar nerve in UCL reconstruction (UCLR) in patients with preoperative ulnar nerve symptoms, as literature supports both not decompressing the nerve as well as ulnar nerve transposition (UNT). Hypothesis/Purpose: The purpose of this study was to compare subjective clinical outcomes and return-to-sports (RTS) metrics between patients who received UNT during UCLR and a matched cohort who underwent UCLR alone. We hypothesized that there would be no significant difference in patient outcomes or RTS metrics between the cohorts. Study Design: Cohort study; Level of evidence, 3. Methods: Using an institutional database, patients who underwent UCLR with UNT between 2007 and 2017 were retrospectively identified. These patients were matched based on sex, age at surgery (±3 years), and body mass index (±2 kg/m2) to a comparison group that underwent UCLR alone. Patients completed the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, the Timmerman and Andrews elbow score, the Conway-Jobe scale, and custom patient satisfaction and RTS questionnaires. Results: Thirty patients who underwent UCLR with concomitant UNT and 30 matched patients who underwent UCLR without UNT were available for follow-up at a mean of 6.9 (3.4-9.9) and 8.1 (3.4-13.9) years, respectively. The UNT group reported similar KJOC (78.4 in UNT vs 76.8; P = .780), Conway-Jobe (60% excellent in UNT vs 77% excellent; P = .504), Timmerman and Andrews (86.2 in UNT vs 88.8; P = .496), and satisfaction scores (85.3% in UNT vs 89.3%; P = .512) compared with UCLR group. In terms of RTS rate (84% in UNT vs 93% in UCLR; P = .289) and duration required to RTS (11.1 months in UNT vs 12.5 months in UCLR; P = .176), the 2 groups did not significantly differ. Finally, despite significant differences in preoperative ulnar nerve symptoms (100% in UNT vs 7% in UCLR; P < .001), the 2 groups did not statistically differ in the proportion of patients who experienced postoperative ulnar nerve symptoms (13% in UNT vs 0% in UCLR; P = .112). Conclusion: This matched cohort analysis showed no statistically significant differences in patient-reported outcomes and RTS between patients undergoing UCLR with and without UNT.

Effect of High School Showcase Exposures and Timing of Ulnar Collateral Ligament Tear on Professional Baseball Careers in Elite Pitchers

Background: Showcase participation has been considered a risk factor for elbow injuries. It remains unclear whether high school (HS) showcase volume negatively affects pitchers’ career paths. Because pitchers are achieving 90 mph thresholds at younger ages, it is unknown whether shorter time intervals between achieving 90 mph thresholds and dates of ulnar collateral ligament reconstruction (UCL-R), known as time to tear (TTT), may affect career trajectory. Hypothesis: Elite pitchers with higher HS showcase volumes would be less likely to reach Major League Baseball (MLB) level compared with elite pitchers with fewer HS showcase appearances. Elite pitchers with longer TTT intervals would be more likely to achieve MLB level. Study Design: Cohort study; Level of evidence, 3. Methods: Demographic, HS showcase and professional performance, and injury data from pitchers selected in the first 5 rounds of the MLB draft (2011-2017) were gathered from publicly available databases. Continuous and categorical variables were compared for the following subgroups: UCL-R group and pitcher group not undergoing UCL-R; “early” and “late” UCL-R groups; and pitchers achieving and pitchers not achieving MLB level. Multivariable analysis was performed using logistic regression. Standard deviations of ±1 SD were used to define early career versus late career UCL-R subgroups after normal distribution was confirmed (Shapiro-Wilk test; P = .227). The early UCL-R group was defined as those pitchers undergoing UCL-R ≤−1 SD from the mean age at first injury (group mean age, 19.43 years), whereas the late UCL-R group was defined as ≥+1 SD from that age (group mean age, 25.19 years). Results: Of 611 pitchers, 455 (74.5%) had HS showcase performance data, and 608 (99.5%) had professional performance data. In total, 184 (30.1%) pitchers underwent UCL-R. Fewer pitchers who underwent early UCL-R achieved the MLB level compared with pitchers who underwent late UCL-R (48.1% vs 86.2%; P = .006). Elite pitchers who pitched in ≥10 showcases in HS had half the odds of achieving the MLB level compared with pitchers who participated in <10 HS showcases (adjusted odds ratio, 0.50; 95% CI, 0.29-0.86; P = .012). For every year longer that an elite pitcher did not tear his UCL after achieving the 90 mph threshold at an HS showcase (TTT after 90 mph [per year]), the likelihood of achieving the MLB level increased by 24% (adjusted odds ratio, 1.24; 95% CI, 1.02-1.52; P = .032). Conclusion: Higher HS showcase volume in elite pitchers was associated with a lower likelihood of achieving MLB level. A longer TTT after 90 mph (per year) was significantly associated with achieving MLB level in elite pitchers.

Is fantasy baseball score a viable outcome measure for professional baseball pitchers after undergoing Tommy John surgery?

Although on-field performance metrics are useful in measuring overall success of ulnar collateral ligament (UCL) reconstruction (UCLR) in professional baseball pitchers, they may not comprehensively quantify athletic performance after returning to playing in the league. To utilize fantasy baseball score (FBS) as a novel and objective outcome to assess the quality of return to play in major league baseball (MLB) pitchers who went back to professional pitching after UCLR. This is a retrospective observational cohort study of 216 established MLB pitchers who underwent UCLR while in the MLB between the years 1974 and 2018. Pitchers who either started in at least 45 games or pitched 90 relief games in the 3 years leading up to injury were included. FBS was calculated using 3 different scoring methods: ESPN (Entertainment and Sports Programming Network) (FBS-ESPN), Yahoo (FBS-Yahoo), and CBS (Columbia Broadcasting System) (FBS-CBS). Return to play, games played, innings pitched, earned runs, strikeouts, walks, hits allowed, hit batsman, and quality starts were also collected. Performance records were compiled for 3 years prior to and after the return to MLB. Players' pre-injury performance was used as a historic control group. Multivariate linear regression analysis was used to detect trends between seasons, controlling for year of surgery, and number of games. The mean age of the cohort at the time of surgery was 30.0±3.5 years. One hundred seventy-nine of 216 players (83%) returned to MLB play, taking an average of 16.6±5.8 months. One hundred thirty-six of 179 (76%) remained in the league for 3 seasons. After adjusting for year of surgery, pitchers earned significantly fewer points for FBS-CBS (616.45±332.42 vs. 389.12±341.06; P<.001), FBS-Yahoo (801.90±416.88 vs. 492.57±428.40; P<.001), and FBS-ESPN (552.76±275.77 vs. 344.19±300.45; P<.001) after their injury. Also pitchers played in fewer games, pitched fewer innings, and had a decline in all measured on-field performance statistics. FBS may represent a useful outcome measure to objectively assess the quality of return to play in a professional baseball pitcher who returned to play in MLB after UCLR.

Outcomes Following Arthroscopic Posteromedial Osteophyte Resection and Risk of Future Ulnar Collateral Ligament Reconstruction.

Despite successful return to sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of removing this osteophyte is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who have an isolated posteromedial osteophyte resection progress to require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophyte in overhead athletes and determine if overhead athletes who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. The authors hypothesized that there would be a high rate of RTS following osteophyte resection and that players who underwent arthroscopic posteromedial osteophyte resection would have a >10% risk of requiring a subsequent UCLR or UCL repair. All patients who underwent elbow arthroscopy from 2010-2020 at a single institution were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms and had no history of prior elbow surgery. Primary outcomes included RTS rate, complications, subsequent shoulder and/or elbow injury/surgery and several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews Elbow score, Conway-Jobe score). Overall, 36 overhead athletes were evaluated at 5.1 ± 3.4 years postoperatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. 77% of overhead athletes RTS and had a mean KJOC score of 70 and satisfaction score of 75, with 89% of athletes having either an excellent (73%) or good (16%) Conway-Jobe score at long-term follow-up. Subsequent UCLR was required in 18% (n=5) of baseball pitchers at a median of 13 months postop. Three of the five UCLR were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months postop), while the other two UCLRs were performed at 6.2 and 7.5 years postop. Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic resection of a posteromedial osteophyte for posteromedial impingement have an 18% risk of subsequent UCLR.

Similar Biomechanics Between the Double-Cortical Button and Docking Techniques for Ulnar Collateral Ligament Reconstruction: A Cadaveric Evaluation.

The docking technique is widely used to perform ulnar collateral ligament (UCL) reconstructions because of its high failure torque and reliable clinical outcomes. A double-cortical button technique was recently described, with advantages including the ability to tension the graft at the ulnar and humeral attachments and the creation of single bone tunnels. To compare the biomechanics between the docking and double-button UCL reconstruction techniques using cadaveric specimens. We hypothesized that there would be no difference in postoperative stiffness or maximum strength between the techniques. Controlled laboratory study. Eight matched pairs of cadaveric elbow joints underwent controlled humeral valgus torsion cycles in a test frame. Toe region stiffness, elastic region stiffness, and maximum torque were measured during a 4-step protocol: intact, injured, reconstructed (10 and 1000 cycles), and ramp to failure. Graft strains were calculated using 3-dimensional motion capture. After 10 cycles, intact ligaments from the docking and double-button groupsexhibited mean ± SD elastic torsional stiffness of 1.60 ± 0.49 and 1.64 ± 0.35 N·m/deg (P = .827), while docking (1.10 ± 0.39 N·m/deg) and double-button (1.05 ± 0.29 N·m/deg) reconstructions were lower (P = .754). There were no significant differences in maximum torque between the docking (3.45 ± 1.35 N·m) and double-button (3.25 ± 1.31 N·m) groups (P = .777). Similarly, differences in maximum graft strains were not significant between the docking (8.1% ± 7.2%) and double-button (5.5% ± 3.1%) groups (P = .645). The groups demonstrated similar decreases in these measures after cyclic loading. Ramp-to-failure testing showed no significant differences in ultimate torque between the docking (8.93 ± 3.9 N·m) and double-button (9.56 ± 3.5 N·m) groups (P = .739). The biomechanical behavior of the double-button technique was not significantly different from that of the docking technique. Both reconstruction techniques restored joint stability, but neither fully recapitulated preinjury joint stiffness. With its procedural advantages, results preliminarily support the use of the double-button reconstruction technique for UCL reconstruction as a reliable single-tunnel technique for primary or revision cases.

Lack of race/ethnic minority representation in ulnar collateral ligament reconstruction in baseball athletes: a systematic review

ABSTRACT Objectives To assess the reporting and representation of ethnic and racial minorities in comparative studies of ulnar collateral ligament (UCL) injuries and treatment in baseball athletes. Methods A systematic review of the literature was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. The literature search was conducted by two independent reviewers using the PubMed, Scopus, and Cochrane Library databases. Studies were included if they were UCL of the elbow clinical comparative studies, including randomized clinical trials, cohort studies, case series, and epidemiological studies. Studies were excluded if they were related to ulnar collateral ligament of the thumb, lateral ulnar collateral ligament of the elbow, biomechanical studies, non-surgical studies, non-baseball studies, and systematic reviews and meta-analyses. The Methodological Index for Non-Randomized Studies (MINORS) criterion was used to assess quality of studies included. Results A total of 108 studies were included for analysis, of which only one reported race and ethnicity in their demographics. Additionally, of the 108 studies included, only four reported Country of Origin, a subset of Race and Ethnicity, in their demographics. Conclusion Race and Ethnicity demographics are scarcely reported in comparative studies evaluating ulnar collateral ligament reconstruction. Future studies evaluating similar populations should strongly consider reporting racial and ethnic demographics as this may provide clarity on any potential effect these might have on post-surgical outcomes, particularly in high-level pitchers.

Biomechanical comparison of ulnar collateral ligament reconstruction with single-tunnel proximal suspensory fixation versus modified docking technique

Despite technical advancement, elbow ulnar collateral ligament (UCL) reconstruction is a challenging procedure due to the limitations regarding the challenging tunnel placement and potential injury to the ulnar nerve. Furthermore, current techniques for reconstruction and repair are inferior functionally and biomechanically when compared to native UCL tissue. A modified docking technique using a single-tunnel proximal suspensory fixation may reduce complications and potentially provide a technique for UCL reconstruction that is biomechanically superior. Decreasing the number of bone tunnels decreases the number of places that bone tear through could occur. The purpose was to evaluate and compare the biomechanical performances for 2 elbow UCL reconstruction techniques: (1) standard docking technique (SD) and (2) a proximal single tunnel (PST) technique using a suspensory fixation. We hypothesized that the PST technique would be biomechanically superior to the SD technique. Twelve matched pairs of cadaveric elbows were dissected and fixed at 70 degrees for biomechanical testing. Gracilis grafts were used for a docking reconstruction and the modified reconstruction with a PST suspensory fixation. A cyclic valgus torque protocol was used to precondition specimens for either reconstruction technique and the ulnohumeral gapping was then assessed. Following gapping measurements, postsurgical specimens underwent a valgus rotation applied at a rate of 5°/s until the anterior band of the UCL failed or fracture occurred. Ultimate load to failure, stiffness, and mode of failure were recorded. There were no statistical differences between the two groups. Mean rotational stiffness of the SD (2.3±0.6 Nm/deg) compared to the PST (1.9±0.7 Nm/deg) (P=.41) and mean ultimate failure torque of the SD (30.5±9.2 Nm) compared to the PST (30.9±8.6 Nm) (P=.86) were similar. There was also no statistically significant difference (P=.83) when comparing the native UCL ulnohumeral gapping (6.0±2.0 mm) to the mean ulnohumeral gapping of the SD reconstruction (6.0±1.8 mm). This study compares the biomechanical strength of elbow UCL reconstructions performed using the SP technique to that of a PST technique. Among all tested parameters, including ultimate failure torque, stiffness, and ulnohumeral gapping, there were no statistically significant differences between the 2 techniques.

Biomechanical comparison of two InternalBrace™ reinforced thumb ulnar collateral ligament reconstruction techniques.

Chronic ulnar collateral ligament ruptures of the thumb metacarpophalangeal joint are often not eligible for direct surgical repair and ligament reconstruction could be considered. Several reconstruction techniques are published, with different types of configurations and fixation methods of the tendon grafts. However, failure of the reconstruction with recurrent instability is still a problem, despite stable graft to bone fixation. Augmentation of the free tendon graft with non-resorbable suture material is gaining popularity, aiming to withstand elongation or rupture of the graft. The purpose of this study was to compare two different augmented ulnar collateral ligament reconstruction methods in a cadaver model. Ten matched pairs of cadaveric upper extremities were used. The thumbs were disarticulated at the trapezometacarpal joint and the ulnar collateral ligament was excised then reconstructed with InternalBrace™ reinforced tendon graft, which was fixed to the bones using either a Tenodesis screw or DX Swivelock® anchor. The thumbs were biomechanically tested with valgus stress, while the force and displacement were simultaneously measured and plotted. The mean (SD) load at clinical failure and maximum load were 19.4 (5.3) and 31.4 (9.5) N in the Tenodesis group, and 21.0 (10.0) and 31.4 (13.9) N in the DX SwiveLock® group, respectively. None of these differences were significant. These results are comparable with previous publications. The Tenodesis screw and the DX SwiveLock® thumb ulnar collateral ligament reconstruction with InternalBrace™ reinforced free tendon graft showed equal strength, both methods are feasible alternatives in the clinical setting.

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.

Increasing rates of ulnar collateral ligament repair outpace reconstruction in isolated injuries: review of a Texas surgical database

The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges. A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups. A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N=25) to 2019 (N=315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P<.001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P=.05). There were no differences among commonly associated procedures including ulnar nerve surgery (P=.217), elbow arthroscopy (P=.092), and platelet-rich plasma injection (P=.837) with no differences in patient-level charges at any time point (P=.47). While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n=20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P<.001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P<.001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique.

Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously. Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque. Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P=.002). The DDA mean cyclic stiffness was significantly greater than the Native (P<.001), DD (P=.025), and MD (P<.001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51°±1.59°) and least for the DDA group (1.01°±0.57°) but did not reach statistical significance. Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.

Psychological Factors Associated With Return to Play After Ulnar Collateral Ligament Reconstruction: A Systematic Review.

Background:The role of psychological factors in return to play (RTP) after ulnar collateral ligament (UCL) reconstruction remains unclear.Purpose:To perform a systematic review of the literature to (1) identify the specific psychological factors that affect RTP after UCL reconstruction and (2) determine the proportion of failures to RTP after UCL reconstruction because of psychological factors.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted. We queried the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science databases to identify studies examining psychological factors and RTP after UCL reconstruction. Data pertaining to study characteristics and design, clinical and demographic characteristics, and psychological factors were collected. Patients were pooled across included studies, weighted means were calculated, and descriptive statistical analysis was performed.Results:A total of 8 studies consisting of 378 patients were included for analysis. The mean time to RTP was 12.2 months, and the overall RTP rate was 89.4%. Psychological factors affecting RTP included loss of interest, fear of reinjury, individual personality traits, personal reasons, and psychological concerns. While clinical factors accounted for 46.2% (n = 24) of failures to RTP, psychological factors comprised 40.4% (n = 21) of the reasons for failure to RTP. The most commonly cited psychological factors affecting RTP were loss of interest (n = 15 [28.8%]) and fear of reinjury (n = 3 [5.8%]).Conclusion:Psychological factors represented a substantial proportion of failures to RTP after UCL reconstruction, especially in adolescent athletes. Future prospective studies and multicenter initiatives are needed to more thoroughly evaluate the psychological concerns of patients before and after UCL reconstruction.

Retrospective Analysis of Ulnar Collateral Ligament Reconstructions in Major League Baseball Pitchers: A Comparison of the "Tall and Fall" Versus "Drop and Drive" Pitching Styles.

Background:Previous pilot research has investigated differences in elbow valgus torque between the “tall and fall” (TF) and “drop and drive” (DD) pitching styles. Whether one of these pitching styles is associated with a greater rate of ulnar collateral ligament reconstruction (UCLR) is currently unknown.Purpose:To determine the proportion of Major League Baseball (MLB) pitchers using the TF and DD pitching styles who underwent UCLR over a 10-year period.Study Design:Cross-sectional study; Level of evidence, 3.Methods:The demographic characteristics of pitchers who underwent UCLR between 2007 and 2017 were obtained via the open-source database MLB Player Analysis Tommy John Surgery List. Other information, such as previous UCLR and pitching videos and graphics, was obtained from other open-source databases. A comprehensive, 2-dimensional, kinesiology-based multicomponent definition of each pitching style was formulated and used to categorize the included pitchers into the TF and DD groups. Statistical comparisons and contrasts were made using chi-square and Pearson correlation tests.Results:Included were 223 MLB pitchers (mean ± SD age, 27.5 ± 3.6 years; body mass index [BMI], 27.6 ± 2.2; throwing velocity, 92.9 ± 2.6 mph [149.5 ± 4.2 km/h]) who underwent UCLR between 2007 and 2017. Of these pitchers, 162 were categorized as TF pitchers (72.6%) and 61 as DD pitchers (27.4%). Pitching velocity for injured pitchers was significantly correlated to BMI (P < .001). We found no significant associations of pitching style with year of UCLR (P = .941), BMI (P = .549), age (P = .647), handedness (P = .501), or average pitch velocity (P = .921).Conclusion:The study findings demonstrated that a higher proportion of UCL-injured MLB pitchers (72.6%) used the TF pitching style. Further research is needed to explore the potential association between pitching style and UCL injury.

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.

Morphologic analysis of the sublime tubercle: considerations in the approach to ulnar collateral ligament reconstruction.

Given the increased incidence of ulnar collateral ligament (UCL) injuries and the projected increase in reconstruction procedures, a robust understanding of the morphologic location of the sublime tubercle is paramount to anatomic reconstruction. There is limited research evaluating the morphology of the sublime tubercle of the proximal ulna in an anterior-to-posterior plane. Twenty-five computed tomography (CT) scans of intact proximal elbow joints for patients were selected using a de-identified database. Cases with history of fracture or surgical intervention to the elbow joint were excluded. These CT scans were then imported into the Mimics Innovation Suite 24.0 software to analyze the sublime tubercle angle from the midpoint of the trochlear notch. All left elbow angle and clock-face values were converted to right elbow values for analysis. The average sublime tubercle angle from the midpoint of the trochlear notch was 282.53 degrees. The angle was converted to a clock face descriptor which located the sublime tubercle at 9.42. Our findings demonstrate that, in the non-throwing population, the morphology of the sublime tubercle can be expected to have a consistent medial location between 9 and 10 o'clock or 2 and 3 o'clock on the contralateral elbow. In relation to the proximal ulnar landmarks, the sublime tubercle, in the non-throwing population, has a consistent relative location.

YouTube videos on ulnar collateral ligament reconstruction are highly variable in terms of reliability and quality: A quantitative analysis.

Ulnar collateral ligament reconstruction (UCLR) is commonly performed on adolescent athletes, who often turn to online sources such as YouTube for health information. The purpose of this study was to retrospectively review the accuracy, reliability, and quality of UCLR videos using validated scoring instruments. YouTube was queried for "Tommy John surgery," "UCL reconstruction," and "ulnar collateral ligament reconstruction." After categorization by physician, nonphysician/trainer, patient or commercial source, videos were assessed for reliability and quality using the Journal of the American Medical Association (JAMA) benchmark criteria (0-4) and DISCERN tool (16-80). 104 videos were included in the final analysis. 74% of videos (77/104) were made by physicians. The mean JAMA and DISCERN scores for all videos were 3.1 ± 0.8 and 46.1 ± 8.5, respectively. The majority of videos were rated as "fair" based on DISCERN score (56/104, 53.8%). JAMA scores were significantly higher for physician videos compared to nonphysician videos (3.3 ± 0.8 vs 2.6 ± 0.7, p < 0.0001), but no such difference was found for DISCERN scores (46.3 ± 7.7 vs 45.3 ± 10.57, p = 0.43). Physicians should be cognizant of the quality and reliability of YouTube videos when instructing patients on information sources related to UCLR.