Treatment of Ulnar Collateral Ligament Tears of the Elbow: Is Repair a Viable Option?

Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review

PURPOSE

To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft.

METHODS

A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure.

RESULTS

The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure.

CONCLUSIONS

Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

Trends in Elbow Ulnar Collateral Ligament Repairs and Reconstructions and an Analysis Between Low- and High-Volume Surgical Centers: A 10-Year Study in New York State

Background

Elbow ulnar collateral ligament (UCL) reconstruction (UCLR) is the gold standard for operative treatment of UCL tears, with renewed interest in UCL repairs.

Purpose

To (1) assess trends in rates of UCLR and UCL repair and (2) identify predictors of complications by demographic, socioeconomic, or surgical center volume factors.

Study Design

Descriptive epidemiology study.

Methods

Patients who underwent UCLR or UCL repair at New York State health care facilities between 2010 and 2019 were retrospectively identified; concomitant ulnar nerve procedures among the cohort were also identified. Surgical center volumes were classified as low (<99th percentile) or high (≥99th percentile). Patient information, neighborhood socioeconomic status quantified using the Area Deprivation Index, and complications within 90 days were recorded. Poisson regression analysis was used to compare trends in UCLR versus UCL repair. Multivariable regression was used to determine whether center volume, demographic, or socioeconomic variables were independent predictors of complications.

Results

A total of 1448 UCL surgeries were performed, with 388 (26.8%) concomitant ulnar nerve procedures. UCLR (1084 procedures; 74.9%) was performed more commonly than UCL repair (364 procedures; 25.1%), with patients undergoing UCL repair more likely to be older, female, and not privately ensured and having undergone a concomitant ulnar nerve procedure (all P < .001). With each year, there was an increased incidence rate ratio for UCL repair versus UCLR (β = 1.12 [95% CI, 1.02-1.23]; P = .022). The authors identified 2 high-volume centers (720 UCL procedures; 49.7%) and 131 low-volume centers (728 UCL procedures; 50.3%). Patients undergoing UCL procedures at high-volume centers were more likely to be younger and male and receive workers' compensation (all P < .001). UCL repair and ulnar nerve-related procedures were both more commonly performed at low-volume centers (P < .001). There were no significant differences in 3-month infection, ulnar neuritis, instability, arthrofibrosis, heterotopic ossification, or all-cause complication rates between low- and high-volume centers. The only significant predictor for all-cause complication was Medicaid insurance (OR, 2.91 [95% CI, 1.20-6.33]; P = .011).

Conclusion

A rising incidence of UCL repair compared with UCLR was found in New York State, especially among female patients, older patients, and nonprivate payers. There were no differences in 3-month complication rates between high- and low-volume centers, and Medicaid insurance status was a predictor for overall complications within 90 days of operation.

Elbow Ulnar Collateral Ligament (UCL) Repair Using Suture Augmentation, Anchors, and Bone Tunnels

Ulnar collateral ligament (UCL) repair with suture augmentation has been increasingly used to treat UCL pathology in overhead athletes. For the appropriately indicated patient, UCL repair with suture augmentation without reconstruction has promising results. Advantages of repair with suture augmentation include earlier return to sport, low complication rate, and decreased operative time since there is no need for graft harvest. Previously reported techniques use suture anchors with high-tensile and collagen-coated nonabsorbable sutures. This article provides an alternative augmentation method using a combination of anchors and bone tunnels to obtain an isometric repair.

Factors Important to Patient Decision-Making After Ulnar Collateral Ligament Injury in Competitive High School and Collegiate Baseball Players

Background

Patients are faced with several treatment decisions after an ulnar collateral ligament (UCL) injury: nonoperative versus operative treatment, repair versus reconstruction, and immediate versus delayed surgery.

Purpose/Hypothesis

The aim of this study was to investigate the factors important to patients when deciding which treatment to pursue after a UCL injury. We hypothesized that (1) length of time away from sports and seasonal timing would be important to patients and (2) treatment decision-making would be heavily influenced by how many and which seasons of their baseball career would be missed.

Study Design

Cross-sectional study.

Methods

High school and collegiate baseball players with UCL tears treated at an academic institution were surveyed retrospectively on their sports participation at the time of injury and their UCL injury treatment decisions. Respondents rated the influence of various factors on a 5-point Likert scale, and they selected the top 3 factors and the single most important factor influencing their treatment decisions. Multiple logistic regression analysis was used to assess the relationship between player characteristics and factors important to their treatment decision.

Results

A total of 83 athletes completed the survey; 40 were in high school and 43 were in college at the time of injury; 7 were treated nonoperatively and 76 underwent surgery (66 immediately and 10 in a delayed fashion), 10 with UCL repair and 66 with UCL reconstruction. The ability to play competitive baseball in the long term was very important or extremely important to 90% of players, while the ability to play in the short term was very important or extremely important to 17%. Length of recovery and seasonal timing were also important factors for 53% and 54% of players, respectively, and almost all (90%) highly valued advice from a surgeon. Possible failure of nonoperative treatment leading to increased time away and the possible loss of 2 consecutive baseball seasons heavily influenced decision-making in 41% of respondents.

Conclusion

Survey respondents were driven by the desire to play baseball in the long term. Treatment decisions were influenced by the length of recovery and by the seasonal timing of their injury, both of which affect how many and which seasons of baseball a player may miss. Patients found advice from their surgeon to be extremely important to decision-making.

Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies

Background

Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads.

Purpose

To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction.

Study Design

Systematic review.

Methods

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases.

Results

After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008).

Conclusion

MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.

Editorial Commentary: Diagnosis, Treatment, Rehabilitation and Return to Sport After Ulnar Collateral Ligament Injury: Agreement Does not Equal Consensus

Tommy John surgical reconstruction for ulnar collateral ligament injuries was first described by Frank Jobe in 1974. Although he estimated the chance for successful return very low, John, famous baseball pitcher, was able to return to play for another 14 years. Modern techniques and better understanding of anatomy and biomechanics have now resulted in a return-to-play rate of more than 80%. Ulnar collateral ligament injuries occur mainly in overhead athletes. Generally, partial tears can be treated nonoperatively, but in baseball pitchers, success rates are less than 50%. Complete tears often require surgery. Primary repair or reconstruction are feasible options, and the choice will depend not only on the clinical scenario, but also the surgeon. Unfortunately, the current evidence is not convincing, and a recent expert consensus study exploring diagnosis, treatment options, rehabilitation, and return to sports showed agreement among the experts, but not necessarily a consensus.

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

Background

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.

Purpose/Hypothesis

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.

Study Design

Cohort study; Level of evidence, 3.

Methods

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).

Results

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.

Conclusion

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.

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.

Change in humeral anchor position significantly affects isometry in ulnar collateral ligament repair: a 3-dimensional computer modeling study

BACKGROUND

Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. Although previous literature has illustrated the importance of tunnel position on restoring graft isometry in reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. The purpose of this study is to design a 3-dimensional (3D) elbow model to understand the effect of anchor location on UCL repair isometry.

METHODS

A 3D computer model of an elbow joint was created using computed tomographic and magnetic resonance imaging MRI scans from a single patient. The humeral and ulnar attachments of the UCL were plotted using 3 methodologies: (1) geometric cloud mapping and (2) quantitative measurements from the anatomic studies by Camp et al and (3) Frangiamore et al. A 3.5-mm-diameter clockface was placed on each attachment site, which allowed for simulation of 12 distinct 1.75-mm deviations in anchor position. The 3 models were ranged through 0°-120° at 10° increments, and the 3D distances were measured between the ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and construct lengths were again measured to evaluate changes in isometry. A paired Student t test was performed to determine if there was a significant difference in isometry between the humeral and ulnar anchor deviations.

RESULTS

Using method 1, the UCL repair length at 90° of elbow flexion was 26.8 mm. This construct underwent 13.6 mm of total excursion for a 46.4% change in length throughout its arc of motion. Method 2 produced a 19.3-mm construct that underwent 0.8 mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5-mm construct that underwent 2.3 mm of excursion for a 9.4% length change. Identifying ligament footprints using the quantitative anatomic measurements from Camp et al and Frangiamore et al improved construct isometry through 120° of flexion (length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique alone (46.4% length change). Humeral anchor deviations produced a significant increase in repair construct excursion compared with ulnar anchor deviations (P < .001).

CONCLUSION

When performing UCL repair, small deviations in humeral anchor position may significantly influence ligament repair isometry. Using quantitative anatomic data may help identify anchor positions with improved repair isometry. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics.

The lateral collateral ligament complex of the elbow in a Thai population: an anatomical study of 56 cadaveric specimens

The purpose of this study was to investigate the anatomical features of the lateral collateral complex (LCC) of the elbow in a Thai population. We dissected 56 cadaveric elbows and described the LCC three-dimensionally in sagittal and coronal planes. We found that the characteristics differed from previous reports in other ethnic populations. In the sagittal plane, the centre of the origin of the LCC was located 3 mm anteriorly and 4 mm inferiorly to the apex of the lateral humerus epicondyle, and in the coronal plane it was 4 mm deep. The vertical distance between the origin of the lateral ulnar collateral ligament (LUCL) and the lateral epicondyle and the distance from the LUCL insertion to the border of the ulnar bone differed significantly between sexes. These data may be useful for surgeons during reconstruction of injures to the LCC of the elbow.Level of evidence: V.

Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction From 2007 to 2016: A Population-Based Study of a Large Private Insurance Database

Background: Ulnar collateral ligament (UCL) reconstruction and UCL repair of the elbow are commonly performed procedures, resulting in high return-to-play rates. Whether the incidence rate of UCL reconstruction vs UCL repair has changed over time is not currently known. Purpose/Questions: We sought to assess temporal trends in the incidence rates of UCL repair and UCL reconstruction and to identify factors associated with UCL reconstruction. We hypothesized that UCL repair would demonstrate an increased incidence overall in recent years with an associated decline in UCL reconstruction rates. Methods: Using the PearlDiver Research Program to query the Humana administrative claims database, we identified patients who had undergone UCL repair and/or reconstruction from 2007 to 2016. Patients were stratified by age (15-19; 20-29; 30-49 years), sex, and year (2007-2011 vs 2012-2016). Poisson regression analysis (continuous variables) was used to calculate the incidence risk ratio (IRR); chi-square tests were performed for categorical variables, and odds ratios were calculated with 95% confidence intervals (CI). Results: The incidence rate of UCL repair was greater in 2012-2016 than in 2007-2011 (IRR: 1.86, 95% CI: 1.16-2.96). The incidence rate of UCL reconstruction vs UCL repair was greater for patients aged 15 to 19 years (IRR: 3.37, 95% CI: 1.97-5.77) but not patients aged 20 to 29 years (IRR: 0.89, 95% CI: 0.49-1.59) as compared with patients aged 30 to 49. Males aged 19 years were more likely than females to undergo UCL reconstruction (IRR: 10.09, 95% CI: 1.37-3.45). Conclusion: While UCL procedures are becoming more popular, our retrospective analysis showed that young males are preferentially treated with UCL reconstruction, warranting further investigation into these trends.

Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes

Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis

Purpose

To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair.

Methods

A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ² tests were used to determine differences between group proportion categorical variables. Significance was considered at a P ≤ .05.

Results

From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South (P < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females (P < .01).

Conclusions

MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin.

Level of Evidence

IV, Therapeutic Case Series.

Rehabilitation Following Ulnar Collateral Ligament Reconstruction in Overhead-Throwing Athletes

»

The prevalence of ulnar collateral ligament (UCL) injury and UCL reconstruction (UCL-R) continues to rise, causing morbidity in overhead-throwing athletes.

»

Postoperative rehabilitation protocols are essential for proper healing of the reconstructed ligament and safely returning athletes to competition, yet there is no uniformly accepted standard of care.

»

UCL-R rehabilitation has traditionally been guided by expert opinion and conventional wisdom rather than scientific studies, resulting in substantial variability in rehabilitation practices, time to return to play, and outcomes.

»

Current research efforts aim to closely investigate the biomechanical implications of UCL-R and overhead throwing to better guide rehabilitation and to improve competitive performance and outcomes.

»

Additional biomechanical and scientific studies on rehabilitation modalities and timing are warranted for systematic analysis, optimization, and standardization of UCL-R rehabilitation.

Return to Play After Platelet-Rich Plasma Injection for Elbow UCL Injury: Outcomes Based on Injury Severity

Background:

Ulnar collateral ligament (UCL) injuries of the elbow are uncommon in the general population but prevalent in the athletic community, particularly among baseball players. Platelet-rich plasma (PRP) injection therapy has become a popular nonoperative adjuvant treatment for such injuries to help reduce recovery time and avoid surgery.

Purpose/Hypothesis:

To analyze patient outcomes by injury severity and identify injury types that responded most favorably and unfavorably to PRP treatment. It was hypothesized that PRP therapy would prove to be most beneficial in the treatment of lower-grade, partial UCL tears and less effective in the treatment of more severe, complete UCL tears.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A cohort of 50 patients with UCL injuries in their dominant elbow, diagnosed by MRI (magnetic resonance imaging) arthrogram, underwent PRP therapy in conjunction with an established rehabilitation program. UCL injuries were classified by MRI as low-grade partial tear (Type I), high-grade partial tear (Type II), complete tear (Type III), or tear in more than 1 location (Type IV).

Results:

In total, 24 of 39 (61.5%) Type I and II tears, 3 of 3 (100%) Type III tears, and 1 of 8 (12.5%) patients with Type IV tears responded to UCL PRP injection therapy and were able to return to play without surgery. Ten patients required subsequent UCL PRP injections, of which 3 (30%) were able to return to sport without surgery.

Conclusion:

PRP treatment for Types I and II UCL tears shows great promise when combined with physical therapy and a rehabilitation program. Type III UCL tears demonstrated a high rate of success, although with low cohort numbers. Type IV UCL tears did not appear to respond well to PRP injection therapy and often required surgical intervention or cessation of sport. Therefore, PRP treatment does not appear to be appropriate for patients with complete Type IV UCL tears but may enhance recovery and improve outcomes in throwing athletes with Types I, II, and III UCL injuries.

State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes

PURPOSE OF REVIEW

There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes.

RECENT FINDINGS

Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete's performance upon returning to sport. With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.

The Use of Platelet-Rich Plasma for Conservative Treatment of Partial Ulnar Collateral Ligament Tears in Overhead Athletes: A Critically Appraised Topic

Clinical Scenario: Rates of ulnar collateral ligament (UCL) injuries continue to rise in overhead athletes of all ages. Surgical interventions require minimally 6 months and up to 2 years of rehabilitation. Younger athletes and those with partial tears have seen positive results with conservative treatment approaches. Platelet-rich plasma (PRP) continues to be studied with various orthopedic injuries, and its use has the potential to improve return-to-sport rates and reduce recovery time. Focused Clinical Question: Do PRP injections improve conservative treatment outcomes in overhead athletes with partial tears of the UCL compared with conservative treatment alone regarding return to participation? Summary of Search, Best Evidence Appraised, and Key Findings: A literature search was performed to locate all studies investigating outcomes when PRP is included in a conservative treatment program for overhead athletes with partial UCL tears. Three case series qualified and were reviewed. Clinical Bottom Line: Current evidence suggests that including PRP in a conservative treatment program can improve outcomes in overhead athletes with partial UCL tears. Athletes whose treatment included PRP show higher return-to-competition rates and shorter recovery times compared with athletes who used rehabilitation alone. Athletes with grade-1 and proximal-based grade-2 injuries returned to competition at rates comparable with athletes undergoing surgical intervention. For optimal conservative management outcomes, PRP injections should be recommended for treatment of partial UCL tears. Strength of Recommendation: The studies qualifying for inclusion are level 4 evidence based on the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence. The studies are well designed and show consistent results, but higher level studies need to demonstrate similar results to improve the body of evidence. The strength of recommendation is C.

Management of Ulnar Collateral Ligament Injuries in Overhead Athletes

Ulnar collateral ligament injuries of the elbow are frequent among overhead athletes. The incidence of ulnar collateral ligament reconstructions (UCLRs) in high-level players has increased dramatically over the past decade, but the optimal technique of UCLR is controversial. Surgeons need to manage the patients’ expectations appropriately when considering the mode of treatment. This article reviews current studies on the management of ulnar collateral ligament injuries, particularly in overhead athletes.

Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis

BACKGROUND

Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries.

HYPOTHESIS

Players who received PRP injections would have better outcomes than those who did not receive PRP.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation.

RESULTS

Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing (P < .001) and RTP (P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing (P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP (P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery.

CONCLUSION

In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.

Biomechanical Evaluation of a Modified Internal Brace Construct for the Treatment of Ulnar Collateral Ligament Injuries

Background:

Ulnar collateral ligament (UCL) repair augmented with the “internal brace” construct for the management of acute UCL injuries has recently garnered increasing interest from the sports medicine community. One concern with this technique is excessive bone loss at the sublime tubercle, should revision UCL reconstruction be required. In an effort to preserve the bony architecture of the sublime tubercle, an alternative internal brace construct is proposed and biomechanically compared with the gold standard UCL reconstruction.

Hypothesis:

The internal brace repair construct will restore valgus laxity and rotation to its native state and demonstrate comparable load-to-failure characteristics with the 3-strand reconstruction technique.

Study Design:

Controlled laboratory study.

Methods:

For this study, 8 matched pairs of fresh-frozen cadaveric elbows were randomized to undergo either UCL reconstruction with the 3-ply docking technique or UCL repair with a novel internal brace construct focused on augmenting the posterior band of the anterior bundle of the ligament (modified repair-IB technique). Valgus laxity and rotation measurements were quantified through use of a MicroScribe 3DLX digitizer at various flexion angles of the native ligament, transected ligament, and repaired or reconstructed ligament. Laxity testing was performed from maximum extension to 120° of flexion. Each specimen was then loaded to failure, and the method of failure was recorded.

Results:

Valgus laxity was restored to the intact state at all degrees of elbow flexion with the modified repair-IB technique, and rotation was restored to the intact state at both full extension and 30°. In the reconstruction group, valgus laxity was not restored to the intact state at either full extension or 30° of flexion (P < .001 and P = .004, respectively). Laxity was restored at 60° of flexion, but the elbow was overconstrained at 90° and 120° of flexion (P = .027 and P = .003, respectively). In load-to-failure testing, the reconstruction group demonstrated significantly greater yield torque (19.1 vs 9.0 N·m; P < .005), yield angle (10.2° vs 5.4°; P = .007), and ultimate torque (23.9 vs 17.6 N·m; P = .039).

Conclusion:

UCL repair with posterior band internal bracing was able to restore valgus laxity and rotation to the native state. The construct exhibited lower load-to-failure characteristics when compared with the reconstruction technique.

Clinical Relevance:

In selected patients with acute, avulsion-type UCL injuries, ligament repair with posterior band internal bracing is a viable alternative surgical option that, by preserving bone at the sublime tubercle, may decrease the complexity of future revision procedures.

Rehabilitation Variability After Elbow Ulnar Collateral Ligament Reconstruction

Background

Investigations specifically delineating the safest and most efficacious components of physical therapy after ulnar collateral ligament (UCL) reconstruction of the elbow are lacking. As such, while a number of recommendations regarding postoperative therapy have been published, no validated rehabilitation guidelines currently exist.

Purpose

To assess the variability of rehabilitation protocols utilized by orthopaedic residency programs in the United States (US) and those described in the scientific literature.

Study Design

Cross-sectional study.

Methods

Online UCL reconstruction rehabilitation protocols from US orthopaedic programs and from the scientific literature were reviewed. A comprehensive scoring rubric was developed to assess each protocol for the presence of various rehabilitation components as well as the timing of their introduction.

Results

Overall, 22 protocols (14%) from 155 US Electronic Residency Application Service (ERAS) orthopaedic programs and 8 protocols published in the scientific literature detailing UCL reconstruction postoperative rehabilitation were identified and reviewed. After reconstruction, the majority of ERAS and review article protocols (77% and 88%, respectively) advised immediate splinting at 90° of elbow flexion. The mean time to splint discontinuation across all protocols was 2.0 weeks (range, 1-3 weeks). There was considerable variability in elbow range of motion recommendations; however, most protocols detailed goals for full extension and full flexion (>130°) at a mean 5.3 weeks (range, 4-6 weeks) and 5.5 weeks (range, 4-6 weeks), respectively. Significant diversity in the inclusion and timing of strengthening, proprioceptive, and throwing exercises was also apparent. Thirteen ERAS (59%) and 7 review article (88%) protocols specifically mentioned return to competition as an endpoint. ERAS protocols permitted return to competition significantly earlier than review article protocols (29.6 vs 39.0 weeks, respectively; P = .042).

Conclusion

There is notable variability in both the composition and timing of rehabilitation components across a small number of protocols available online. While our understanding of postoperative rehabilitation for UCL reconstruction evolves, outcome-based studies focused on identifying clinically beneficial modalities and metrics are necessary to enable meaningful standardization.

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With a Modified Docking Technique With and Without Suture Augmentation

BACKGROUND

Throwing athletes with ulnar collateral ligament (UCL) injury and symptomatic valgus instability can expect to return to the same or higher level of play. Reconstruction with tendon graft is the dominant method of surgical treatment. Recent evidence suggests that spanning the joint with a suture anchored on both sides is biomechanically equivalent to reconstruction, with faster time to return to play. The authors developed a hybrid UCL reconstruction technique augmented with a suture brace to improve joint stability.

PURPOSE/HYPOTHESIS

The purpose of this study was to biomechanically evaluate a hybrid reconstruction technique and compare its performance to reconstruction without augmentation. The authors hypothesized that (1) both groups would lose stability after the simulated tear and regain stability with treatment, (2) the suture augmentation would improve stability, and (3) the addition of the suture anchors near the bone tunnels would not decrease the strength of the hybrid reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten matched pairs of cadaveric arms were dissected to expose the UCL. Each elbow was mounted on a test frame at 90° of flexion. A cyclic valgus rotational torque was applied to the humerus with the UCL in its intact state and repeated in its surgically torn state. Finally, each specimen received either a hybrid reconstruction with suture brace or a reconstruction and was again put through the cyclic protocol, followed by a valgus rotation load-to-fail protocol.

RESULTS

Gap formation in the torn state for the reconstruction and hybrid reconstruction groups (0.9 ± 0.1 mm and 0.8 ± 0.1 mm, respectively) was significantly higher ( P = .009 and P = .0002) than in the intact state (0.6 ± 0.2 mm and 0.6 ± 0.3 mm, respectively). After the procedures, the hybrid group showed greater resistance to gapping ( P = .017) as compared with the reconstruction group (0.4 ± 0.2 mm and 0.6 ± 0.1 mm). During load to failure, no hybrid reconstructions failed from bone fracture or screw pullout. No statistical differences were found for failure torque ( P = .058) and stiffness ( P = .101). Gap at 10 N·m was significantly lower ( P = .014) for the hybrid reconstruction group than for the reconstruction group.

CONCLUSION

The current study showed that hybrid reconstruction with suture bracing replicated the time-zero strength of traditional UCL reconstruction and may be more resistant to joint gapping during low cyclic load and load to failure. The combination of the bone tunnels and fixation screw holes did not appear to weaken the construct.

CLINICAL RELEVANCE

This study demonstrated that reconstruction with suture bracing has important time-zero stability and strength as compared with the gold standard of UCL reconstruction. This technique may be useful for throwing athletes who need UCL reconstruction.

Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up

The ulnar collateral ligament (UCL) is the primary restraint to valgus angulation at the elbow. Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing. Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation. Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. Here we present the first patient treated with this technique who achieved excellent recovery with return to college level American Football after 4 months. Five years later he has good elbow function and plays at the same level.

Elbow Surgery in Athletes

Injuries and disorders of the elbow in athletes are common especially among throwing athletes. Common injuries encountered in the throwing athlete include ulnar collateral ligament injuries, ulnar neuritis, capitellar osteochondritis dissecans, valgus extension overload with posterior olecranon impingement, olecranon stress fracture, and loose bodies. A thorough knowledge of both the functional anatomy as well as throwing biomechanics are required to properly diagnosis and treat these problems. Nonoperative and surgical techniques have continued to advance over the last 25 years allowing for improved prognosis and return to play for athletes affected with elbow pathology.

Nonreconstruction Options for Treating Medial Ulnar Collateral Ligament Injuries of the Elbow in Overhead Athletes

PURPOSE OF REVIEW

This review aims to describe the nonreconstructive options for treating ulnar collateral ligament (UCL) injuries ranging from nonoperative measures, including physical therapy and biologic injections, to ligament repair with and without augmentation.

RECENT FINDINGS

Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. Proximal avulsion injuries have shown the best results after repair. Currently, there is growing interest in augmentation of UCL repair with an internal brace. The treatment of UCL injuries involves complex decision making. UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes. However, nonreconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries. Future research comparing reconstructive versus nonreconstructive options is necessary.

Ulnar Collateral Ligament Repair With Suture Augmentation

Reconstruction of the ulnar collateral ligament (UCL) remains the gold standard for treating overhead throwing athletes with valgus instability secondary to UCL pathology. Although surgical techniques for reconstruction have evolved over time, current methods allow 90% of patients to return to their preinjury level of activity. Despite encouraging results with reconstruction, UCL repair remains a valuable treatment option for patients with UCL pathology fitting specific criteria. There are a number of advantages associated with a direct repair, and further, the development of collagen-coated sutures for ligament repair augmentation makes this procedure an attractive surgical option under the correct circumstances. This article provides a detailed description and video demonstration of the surgical steps used to perform a UCL repair with suture augmentation.

Reasons for Retirement Following Ulnar Collateral Ligament Reconstruction Among Major League Baseball Pitchers

Background:

Ulnar collateral ligament reconstruction (UCLR) has become an increasingly common procedure among Major League Baseball (MLB) pitchers. The long-term effects of this procedure on the career of an MLB pitcher are largely unknown.

Purpose/Hypothesis:

The purpose of this study was to determine why and when MLB pitchers who underwent UCLR during their careers retired from baseball as compared with controls. We hypothesized that pitchers who underwent UCLR are no more likely than control pitchers to retire from elbow or shoulder problems.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

All MLB pitchers who underwent UCLR were identified through publicly available data. A cohort of pitchers who did not undergo UCLR were matched to pitchers with a history of UCLR, based on sex, age, draft year, and draft round. Of those who were no longer pitching in the MLB, the reason for retirement was determined. Reason for retirement and length of career following UCLR (surgical group) and index year (control group) were determined and compared through prior studies via the MLB HITS database, MLB team websites, and publicly available internet-based injury reports.

Results:

Overall, 153 MLB pitchers who underwent UCLR between 1974 and 2015 are currently retired. Mean ± SD time to retirement was 4.4 ± 4.7 years (range, 0-26 years) after the index year in the control group and 4.4 ± 3.5 years (range, 0-15 years) after surgery in the UCLR group (P = .388). Patients who were status post-UCLR were significantly more likely to be released during the season (34 of 144, 23.6%) than were players who were not status post-UCLR (14 of 144, 9.7%) (P = .002). Shoulder injury as a reason for retirement was more common in the control group than the UCLR group (P = .011). Elbow injury as a reason for retirement was not more common in either group (P = .379). Leg injury as a reason for retirement was more common in the control group (P = .013). Performance as a reason for retirement was more common in the UCLR group than the control group (P < .001).

Conclusion:

MLB pitchers who have undergone UCLR are no more likely to retire from shoulder or elbow injuries than are those who have not undergone UCLR. MLB career length was similar between pitchers with and without a history of UCLR.

Management of ulnar collateral ligament injury in throwing athletes: a survey of the American Shoulder and Elbow Surgeons

BACKGROUND

Amid evidence that the number of ulnar collateral ligament (UCL) reconstructions performed annually is on the rise, there continues to be significant variation among surgeons in the management of UCL injuries. The purpose of this paper was to survey the members of the American Shoulder and Elbow Surgeons (ASES) to assess current trends related to the comprehensive treatment of athletes presenting with UCL injury.

METHODS

An online survey was distributed to the active members of the ASES. The survey was composed of 3 sections assessing the demographics of the survey-takers, presenting 7 distinct fictional clinical case scenarios of athletes with UCL injury, and posing a series of more general questions about operative and nonoperative management of UCL injuries.

RESULTS

There were 159 ASES members who responded to the survey (24% of the active membership); 65 respondents (40.9%) reported >15 years of clinical experience. Of the 7 case scenarios presented, a consensus was reached to indicate the patient for surgery in 4 cases. In all 7 cases, when operative management was the preferred option, a consensus was reached to perform UCL reconstruction. The preferred method of UCL reconstruction among respondents was the docking technique (66.0%); 36.3% of respondents used platelet-rich plasma in their treatment of UCL injuries.

CONCLUSION

The survey presented here shows that an overall experienced and well-trained cohort of surgeons tended to agree and often reached consensus opinions on how to approach UCL injury. Professional athletes and those with complete tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals.