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Buchanan TR, Hones KM, Hao KA, Kamarajugadda S, Portnoff B, Wright JO, King JJ, Wright TW, Kim J, Schoch BS, Roach RP, Aibinder WR. Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years. Sports Health 2024:19417381241249125. [PMID: 38702939 DOI: 10.1177/19417381241249125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
CONTEXT Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management. OBJECTIVE This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation. DATA SOURCES Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022. STUDY SELECTION Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing. RESULTS Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores. CONCLUSION Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.
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Affiliation(s)
| | - Keegan M Hones
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, Florida
| | | | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Jonathan O Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Jongmin Kim
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Ryan P Roach
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Hones KM, Simcox T, Hao KA, Portnoff B, Buchanan TR, Kamarajugadda S, Kim J, Wright JO, King JJ, Wright TW, Schoch BS, Aibinder WR. Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:1185-1199. [PMID: 38072032 DOI: 10.1016/j.jse.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.
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Affiliation(s)
- Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Trevor Simcox
- Department of Orthopaedic Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | | | | | - Jongmin Kim
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.
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Vaswani R, White A, Dines J. Medial Ulnar Collateral Ligament Injuries in Contact Athletes. Curr Rev Musculoskelet Med 2022; 15:474-482. [PMID: 35917095 PMCID: PMC9789220 DOI: 10.1007/s12178-022-09785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review medial ulnar collateral ligament (UCL) injuries in contact athletes. UCL injuries in overhead throwing athletes are typically chronic attenuation due to repetitive valgus stress on the elbow during the throwing motion. As such, UCL reconstruction is commonly performed for these athletes. In contrast, UCL injuries in contact athletes are usually acute ligament tears or avulsions of a ligament with otherwise normal tissue. Nonoperative treatment is typically the first-line treatment for partial injuries. UCL repair may work well for acute complete injuries and may avoid the donor site morbidity of UCL reconstruction. RECENT FINDINGS Most of the literature regarding UCL injuries have been performed in baseball players. Historically, UCL repair has had poor outcomes in baseball players due to the chronic ligament attenuation. Therefore, much of the recent literature has focused on outcomes of UCL reconstruction, which are generally excellent. However, there is a paucity of literature studying outcomes of UCL injuries in contact athletes and those studying UCL repair. One recent study looked at a new technique for UCL repair with collagen-coated fiber tape augmentation in baseball players and found good short-term outcomes. UCL injuries in contact athletes occur typically as acute tears or avulsions. While UCL reconstruction has typically been recommended as the accepted treatment for UCL tears that require operative treatment, UCL repair may be a good alternative in contact athletes.
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Affiliation(s)
- Ravi Vaswani
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.
| | - Alex White
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Joshua Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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CarlLee TL, Rao AJ, Scarola GT, Yeatts NC, Trofa DP, Hamid N, Schiffern SC, Connor PM, Fleischli JE, Saltzman BM. Clinical outcomes of a unique ulnar collateral ligament reconstruction hybrid technique with ulnar-sided suspensory fixation. J Shoulder Elbow Surg 2021; 30:S2-S7. [PMID: 33753270 DOI: 10.1016/j.jse.2021.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/12/2021] [Accepted: 02/21/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar collateral ligament reconstruction (UCLR) is the gold standard for treating ulnar collateral ligament injuries in throwing athletes who have failed conservative treatment. There are several described techniques that produce successful and reproducible outcomes. In addition, there is biomechanical evidence that supports hybrid fixation of the graft with a docking technique on the humeral side and suspensory fixation on the ulnar side. However, as of this writing there are no clinical studies that have reported results. This retrospective case series is the first of its kind to report on clinical outcomes following UCLR with hybrid suspensory fixation. METHODS Fifty throwing athletes who underwent ULCR with hybrid suspensory fixation from 2010-2017 by one of 5 surgeons at a single institution were available at a median follow-up of 7 years. Return to sport, level of sport, and postoperative complications were recorded at final follow-up. RESULTS A total of 50 patients were included in final analysis. Nearly all were able to return to sport at the same level or higher (48/50, 96%). One of these 50 athletes (2%) played professionally, 27 (54%) played collegiately, and 21 (42%) played at the high school level. Seven patients (14%) underwent reoperation following the index procedure. The median (interquartile range) Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 0.098 (0-4.5) at final follow-up. CONCLUSION Hybrid suspensory fixation is a safe and effective technique for UCLR in the throwing athlete. Throwers can expect to return to sport at a very high rate with low risks for postoperative complications.
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Affiliation(s)
| | - Allison J Rao
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Nicholas C Yeatts
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Atrium Health-Musculoskeletal Institute, Charlotte, NC, USA
| | - David P Trofa
- Columbia University Medical Center, New York, NY, USA
| | - Nady Hamid
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Atrium Health-Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Patrick M Connor
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Atrium Health-Musculoskeletal Institute, Charlotte, NC, USA
| | - James E Fleischli
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Atrium Health-Musculoskeletal Institute, Charlotte, NC, USA
| | - Bryan M Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Atrium Health-Musculoskeletal Institute, Charlotte, NC, USA.
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Yu JS, Carr JB, Thomas J, Kostas J, Wang Z, Khilnani T, Liu K, Dines JS. Trends in Patient, Physician, and Public Perception of Ulnar Collateral Ligament Reconstruction Using Social Media Analytics. Orthop J Sports Med 2021; 9:2325967121990052. [PMID: 34250162 PMCID: PMC8239339 DOI: 10.1177/2325967121990052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Social media posts regarding ulnar collateral ligament (UCL) injuries and
reconstruction surgeries have increased in recent years. Purpose: To analyze posts shared on Instagram and Twitter referencing UCL injuries and
reconstruction surgeries to evaluate public perception and any trends in
perception over the past 3 years. Study Design: Cross-sectional study. Methods: A search of a 3-year period (August 2016 and August 2019) of public Instagram
and Twitter posts was performed. We searched for >22 hashtags and search
terms, including #TommyJohn,
#TommyJohnSurgery, and #tornUCL. A
categorical classification system was used to assess the sentiment, media
format, perspective, timing, accuracy, and general content of each post.
Post popularity was measured by number of likes and comments. Results: A total of 3119 Instagram posts and 267 Twitter posts were included in the
analysis. Of the 3119 Instagram posts analyzed, 34% were from patients, and
28% were from providers. Of the 267 Twitter posts analyzed, 42% were from
patients, and 16% were from providers. Although the majority of social media
posts were of a positive sentiment, over the past 3 years, there was a major
surge in negative sentiment posts (97% increase) versus positive sentiment
posts (9% increase). Patients were more likely to focus their posts on
rehabilitation, return to play, and activities of daily living. Providers
tended to focus their posts on education, rehabilitation, and injury
prevention. Patient posts declined over the past 3 years (–28%), whereas
provider posts increased substantially (110%). Of posts shared by health
care providers, 4% of posts contained inaccurate or misleading
information. Conclusion: The majority of patients who post about their UCL injury and reconstruction
on social media have a positive sentiment when discussing their procedure.
However, negative sentiment posts have increased significantly over the past
3 years. Patient content revolves around rehabilitation and return to play.
Although patient posts have declined over the past 3 years, provider posts
have increased substantially with an emphasis on education.
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Affiliation(s)
- Jonathan S Yu
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - James B Carr
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA.,Hospital for Special Surgery Florida, West Palm Beach, FL, USA
| | - Jacob Thomas
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Julianna Kostas
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Zhaorui Wang
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Tyler Khilnani
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Katie Liu
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Joshua S Dines
- Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, New York, USA.,Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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Abstract
PURPOSE OF REVIEW Primarily reported in the overhead throwing athlete, ulnar collateral ligament (UCL) injuries have been extensively studied since Dr. Frank Jobe first described his technique for ulnar collateral ligament reconstruction on professional baseball pitcher Tommy John. While the framework for our understanding of UCL injury was initially established studying the repetitive valgus loading of the throwers' elbow, other sport-related activities in non-throwing athletes can impart similar valgus stress on the medial elbow placing the UCL at risk for injury. The purpose of this review is to evaluate the current literature on UCL injury specifically in the non-throwing athlete. RECENT FINDINGS In the four decades since Dr. Jobe's seminal description of UCL reconstruction, an abundance of literature has been published on UCL injury in the throwing athlete. The evidence evaluating the UCL specifically in the non-throwing athlete, however, is quite scarce. Several small retrospective studies have demonstrated good results with high rates of return to play with focused rehabilitation and non-operative management in non-throwing athletes. Recent evidence has also demonstrated that surgical repair and/or reconstruction of the UCL in this population can produce good outcomes. The level of evidence of these published studies is low and consists primarily of case series without control groups. Further investigation is warranted to determine the optimal treatment algorithm for UCL injury in the non-throwing athlete.
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Affiliation(s)
- Nicholas Ramos
- Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA, 90045, USA.
| | - Orr Limpisvasti
- Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA, 90045, USA
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