Osseous Vascularity of the Medial Elbow After Ulnar Collateral Ligament Reconstruction: A Comparison of the Docking and Modified Jobe Techniques

A systematic review of surgical outcomes of ulnar collateral ligament rupture in the elbow treated with various techniques

When comparing different techniques, there is limited evidence on return-to-play rates and complication rates following ulnar collateral ligament (UCL) surgery. This systematic review aims to assess the outcomes of various UCL surgery techniques. A systematic search of PubMed, Google Scholar, and EMBASE up to May 2024 was performed. Outcome measures included return-to-play rates and postoperative complication rates from relevant articles. Data was analyzed using a chi-square analysis to determine statistical significance. Internal bracing repair demonstrated a return-to-play rate of 93.2 % at the same or higher level of competition, outperforming the rates of 80.5 % for the modified Jobe technique and 82.3 % for docking reconstruction. The docking technique exhibited a minor postoperative complication rate of 2.35 %, significantly lower than the rates of 8.59 % and 8.08 % for modified Jobe and internal bracing techniques, respectively. The modified Jobe technique had a major postoperative complication rate of 1.16 %, while internal bracing had a rate of 3.01 %. The use of internal bracing for anchor repairs demonstrated a statistically significant higher return-to-play rate at the same or elevated levels of competition compared to the reconstruction techniques analyzed. Notably, the docking technique exhibited a significantly lower rate of minor postoperative complications when contrasted with both the modified Jobe and internal bracing methods. Furthermore, the modified Jobe technique was associated with a significantly reduced incidence of major postoperative complications compared to the internal bracing approach.

Differential regional perfusion of the human anterior cruciate ligament: quantitative magnetic resonance imaging assessment

Purpose

Surgical reconstruction is the current standard for ACL rupture treatment in active individuals. Recently, there is renewed interest in primary repair of proximal ACL tears. Despite this, ACL biology and healing potential are currently not well understood. Vascularity is paramount in ACL healing; however, previous ACL vascularity studies have been limited to qualitative histological and dissection-based techniques. The study objective was to use contrast-enhanced quantitative-MRI to compare relative perfusion of proximal, middle, and distal thirds of the in situ ACL. We hypothesized perfusion would be greatest in the proximal third.

Methods

Fourteen cadaveric knees were studied (8 females, 6 males), age 25–61 years. Superficial femoral, anterior tibial, and posterior tibial arteries were cannulated; without intraarticular dissection. Contrast-enhanced quantitative-MRI was performed using a previously established protocol. ACL regions corresponding to proximal, middle, and distal thirds were identified on sagittal-oblique pre-contrast images. Signal enhancement (normalized to tibial plateau cartilage) was quantified to represent regional perfusion as a percentage of total ACL perfusion. Comparative statistics were computed using repeated measures ANOVA, and pairwise comparisons performed using the Bonferroni method.

Results

Relative perfusion to proximal, middle, and distal ACL zones were 56.0% ±17.4%, 28.2% ±14.6%, and 15.8% ±16.3%, respectively (p = 0.002). Relative perfusion to the proximal third was significantly greater than middle (p = 0.007) and distal (p = 0.001). No statistically relevant difference in relative perfusion was found to middle and distal thirds (p = 0.281). Post-hoc subgroup analysis demonstrated greater proximal perfusion in males (66.9% ± 17.3%) than females (47.8% ± 13.0%), p = 0.036.

Conclusion

Using quantitative-MRI, in situ adult ACL demonstrated greatest relative perfusion to the proximal third, nearly 2 times greater than the middle third and 3 times greater than the distal third. Knowledge of differential ACL vascular supply is important for understanding pathogenesis of ACL injury and the process of biological healing following various forms of surgical treatment.

Ulnar Collateral Ligament Tear Location May Affect Return-to-Sports Rate but Not Performance Upon Return to Sports After Ulnar Collateral Ligament Reconstruction Surgery in Professional Baseball Players

BACKGROUND

The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS.

PURPOSE/HYPOTHESIS

The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears.

RESULTS

Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS (P = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits (P = .03), runs (P = .015), and walks (P = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups.

CONCLUSION

Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.

Ulnar Collateral Ligament Reconstruction Technique Utilizing Suture Tape Augmentation

The prevalence of ulnar collateral ligament injuries and reconstructions among overhead throwing athletes has significantly risen in recent years. Surgical reconstruction has become the main treatment modality for athletes who have failed conservative treatment and wish to return to their sport. There has been an increased interest in graft augmentation in ligament reconstruction surgeries as surgeons search for ways to decrease the chance of graft failure. Augmented graft techniques have been described for other procedures. We present a technique that incorporates a cross-linked suture tape into either a palmaris longus or gracilis tendon autograft or allograft for ulnar collateral ligament reconstruction. This may allow for a biomechanically stronger construct because it appears this is the case in other settings. The goal is that this would lead to decreased rates of failure or possibly allow athletes to return at an accelerated rate.

Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique

Background:

In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement.

Purpose/Hypothesis:

The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique.

Study Design:

Controlled laboratory study.

Methods:

A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen.

Results:

The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group (P = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively (P = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique.

Conclusion:

Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times.

Clinical Relevance:

Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.

Do Outcomes or Subsequent Injuries Differ After Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Autograft?

BACKGROUND

Ulnar collateral ligament reconstruction (UCLR) is a successful procedure in professional baseball players. It is unclear whether graft choice affects results.

PURPOSE

Determine performance and rate of return to sport (RTS) in professional baseball players after UCLR and compare performance and RTS rate, as well as injury rates, between players who underwent UCLR with hamstring versus palmaris autograft.

HYPOTHESIS

A high RTS rate exists in professional baseball players after UCLR, with no significant difference in injury rates, RTS rates, or performance specifically related to primary outcome performance variables-WHIP ([walks + hits]/innings pitched), fielding independent pitching (FIP), and wins above replacement (WAR)-between those who undergo UCLR with palmaris versus hamstring autograft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent UCLR with hamstring autograft between 2010 and 2015 were included. Surgical details were gathered from operative reports. Players with hamstring UCLR were compared with a matched control group of players who underwent UCLR with palmaris autograft.

RESULTS

Overall, 195 players underwent UCLR with hamstring autograft. No differences in RTS rates or timing to RTS were found between the hamstring and palmaris groups. Significantly more subsequent injuries to the contralateral lower extremity were seen in the hamstring group versus the palmaris group (25 vs 13, respectively) ( P = .040). More subsequent injuries to the upper extremity were found in the palmaris group versus the hamstring group (73 vs 55, respectively), although this difference was not significant ( P = .052). No consistent differences in performance metrics upon RTS existed between hamstring and palmaris groups, although both groups significantly declined in many performance metrics after surgery. Both hamstring and palmaris groups showed a decline postoperatively in WAR (0.86 vs 0.35 and 1.23 vs 0.34, respectively) and WHIP (1.33 vs 1.44 and 1.36 vs 1.51, respectively); FIP did not decline (4.56 vs 5.27 and 4.51 vs 4.53, respectively). No significant difference in WAR, WHIP, or FIP existed between groups postoperatively.

CONCLUSION

Baseball players who underwent UCLR with hamstring autograft were more likely to sustain a subsequent lower extremity injury, whereas those who underwent UCLR with palmaris autograft had a trend toward sustaining more upper extremity injuries. No difference in performance or RTS rates existed between groups. Both groups significantly declined in WAR and WHIP after UCLR.