Graft diameter does not influence primary stability of ulnar collateral ligament reconstruction of the elbow

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.

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.

Graft Site Morbidity in Elbow Ligament Reconstruction Procedures: A Systematic Review

BACKGROUND

It is unclear which tendon harvest for ulnar or lateral collateral ligament reconstruction has the lowest graft site morbidity rate.

PURPOSES

To obtain graft site morbidity rates after tendon harvest for ulnar and lateral collateral ligament reconstruction procedures.

STUDY DESIGN

Systematic review/Meta-analysis.

METHODS

Studies were eligible if (1) patients had undergone elbow ligament reconstruction procedures; (2) original data for at least 5 patients were available; (3) the article was written in English, German, or Dutch; (4) a full-text article was available; and (5) information about graft site morbidity was available. The review excluded studies about complicated elbow ligament reconstruction procedures due to initial fractures, revision procedures, or circumferential graft techniques; animal studies; (systematic) reviews; and expert opinions. Because the majority of studies were case reports, no selection form or overall scoring system to evaluate methodological quality was used.

RESULTS

The review included 619 patients with an ulnar or lateral collateral ligament reconstruction procedure. The autograft types used included palmaris longus tendon (58%), gracilis tendon (24%), semitendinosus tendon (8%), triceps tendon (7%), toe extensor tendon (<2%), plantaris tendon (<2%), extensor carpi radialis longus tendon (<1%), and Achilles tendon (<1%).

CONCLUSION

Graft site morbidity occurred in 1% of the patients after an ulnar or lateral collateral ligament reconstruction procedure. This study did not have enough samples of all the autograft types to conclude that autograft type and graft site morbidity are unrelated.

Are the hamstrings from the drive leg or landing leg more active in baseball pitchers? An electromyographic study

BACKGROUND

Ulnar collateral ligament reconstruction (UCLR) has become a common procedure among baseball players of all levels. There are several graft choices in performing UCLR, one of which is a hamstring (gracilis or semitendinosus) autograft. It is unclear whether the hamstring muscle from a pitcher's drive leg (ipsilateral side of the UCLR) or landing leg (contralateral side of the UCLR) is more active during the pitching motion. We hypothesized that the landing leg semitendinosus will be more electromyographically active than the drive leg.

METHODS

Healthy, elite male pitchers aged 16-21 years were recruited. Sixteen pitchers (average age, 17.6 ± 1.6 years; 67% threw right handed) underwent electromyographic analysis. Pitchers threw 5 fastballs at 100% effort from the wind-up with electromyographic analysis of every pitch. Activation of the semitendinosus and biceps femoris in both legs was compared within pitchers and between pitchers.

RESULTS

Hamstring activity was higher in the drive leg than in the landing leg during each phase and in sum, although the difference was significant only during the double support phase (P = .021). On within-pitcher analysis, 10 of 16 pitchers had significantly more sum hamstring activity in the drive leg than in the landing leg, while only 4 of 16 had more activity in the landing leg (P = .043).

CONCLUSION

During the baseball pitch, muscle activity of the semitendinosus was higher in the drive leg than in the landing leg in most pitchers. Surgeons performing UCLR using hamstring autograft should consider harvesting the graft from the pitcher's landing leg to minimize disruption to the athlete's pitching motion.

Chronic medial instability of the elbow

Damage to the medial collateral ligament of the elbow from an instability episode usually heals with non-operative treatment. In some cases, residual instability may occur, leading to functional impairment.

Non-operative management can be successful when bracing, taping and therapy are used to stabilise the elbow.

A recent report detailing the efficacy of platelet-rich plasma in effectively treating ulnar collateral ligament (UCL) injuries in throwers has shown promise. However, there remain specific groups that should be considered for repair or reconstruction. These may include throwing athletes, wrestlers and some individuals involved in highly active physical activity which demands stability of the elbow.

The results of surgical repair and reconstruction allowing a return to sports are quite good, ranging from 84% to 94%. Complications are generally low and mostly centred on ulnar nerve injuries.

This report represents a review of the literature concerning valgus instability over the past five years, supplemented by selective older articles where relevant.

Cite this article: EFORT Open Rev 2017;2:1-6. DOI:10.1302/2058-5241.2.160037.

Length of time between surgery and return to sport after ulnar collateral ligament reconstruction in Major League Baseball pitchers does not predict need for revision surgery

HYPOTHESIS

Pitchers who return to sport (RTS) sooner will have a higher risk of revision ulnar collateral ligament reconstruction (UCLR) than those who return later.

METHODS

All professional (major and minor league) baseball pitchers who underwent UCLR between 1974 and 2016 were identified. Date of the index UCLR was recorded. The date of the first game back at any professional level after surgery and the date the pitcher returned to the same level of play (if applicable) were recorded. Length of time between these dates was compared for pitchers who required a revision UCLR and those who did not.

RESULTS

Overall, 569 pitchers (average age, 24.8 ± 4.1 years) underwent UCLR and had reliable game logs after surgery. No statistically significant difference existed in the length of time to RTS at any professional level or at the same professional level between those pitchers who did not require a revision UCLR and those who did (P = .442, P = .238). Pitchers who required revision UCLR returned to any level of play almost 2 months earlier (14.7 vs. 16.5 months) and returned to the same level of play >2 months earlier (15.2 vs. 17.7 months) than matched controls who did not require revision UCLR, although this was not statistically significant (P = .179, P = .204).

CONCLUSION

No statistically significant difference existed in the length of time to RTS after UCLR in professional baseball players who required a revision UCLR and those who did not.

Do Clinical Results and Return-to-Sport Rates After Ulnar Collateral Ligament Reconstruction Differ Based on Graft Choice and Surgical Technique?

Background:

Ulnar collateral ligament reconstruction (UCLR) has become a common procedure performed in overhead-throwing athletes of many athletic levels.

Purpose/Hypothesis:

The purpose of this study was to determine whether clinical outcomes and return-to-sport (RTS) rates differ among patients undergoing UCLR based on graft choice, surgical technique, athletic competition level, handedness, and treatment of the ulnar nerve. We hypothesized that no differences would exist in clinical outcomes or RTS rates between technique, graft choice, or other variables.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All patients who underwent UCLR from January 1, 2004 through December 31, 2014 at a single institution were identified. Charts were reviewed to determine patient age, sex, date of surgery, sport played, handedness, athletic level, surgical technique, graft type, and complications. Patients were contacted via telephone to obtain the RTS rate, Conway-Jobe score, Timmerman-Andrews score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score.

Results:

Eighty-five patients (mean age at surgery, 19.3 ± 4.7 years; 92% male; 78% right hand–dominant) underwent UCLR between 2004 and 2014 and were available for follow-up. Overall, 87% were baseball pitchers, 49.4% were college athletes, and 41.2% were high school athletes. No significant difference existed between the docking and double-docking techniques, graft choice, handedness, sex, activity level, and treatment of the ulnar nerve with regard to clinical outcomes, RTS, or subsequent surgeries (all P > .05). More complications were seen in the docking technique compared with the double-docking technique (P = .036). Hamstring autograft was used more commonly with the docking technique (P = .023) while allograft was used more commonly with the double-docking technique (P = .0006).

Conclusion:

Both the docking and double-docking techniques produce excellent clinical outcomes in patients undergoing UCLR. No difference in outcome scores was seen between surgical technique or graft type. The double-docking technique had fewer complications than the docking technique.

Elbow ulnar collateral ligament injuries in athletes: Can we improve our outcomes?

Injury to the ulnar collateral ligament (UCL) most commonly occurs in the overhead throwing athlete. Knowledge surrounding UCL injury pathomechanics continues to improve, leading to better preventative treatment strategies and rehabilitation programs. Conservative treatment strategies for partial injuries, improved operative techniques for reconstruction in complete tears, adjunctive treatments, as well as structured sport specific rehabilitation programs including resistive exercises for the entire upper extremity kinetic chain are all important factors in allowing for a return to throwing in competitive environments. In this review, we explore each of these factors and provide recommendations based on the available literature to improve outcomes in UCL injuries in athletes.

Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes

Context:

Ulnar collateral ligament (UCL) injuries lead to pain and loss of performance in the thrower’s elbow. Ulnar collateral ligament reconstruction (UCLR) is a reliable treatment option for the symptomatic, deficient UCL. Injury to the UCL usually occurs because of chronic accumulation of microtrauma, although acute ruptures occur and an acute-on-chronic presentation is also common.

Evidence Acquisition:

Computerized databases, references from pertinent articles, and research institutions were searched for all studies using the search terms ulnar collateral ligament from 1970 until 2015.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

All studies reporting outcomes for UCLR are level 4. Most modern fixation methodologies appear to be biomechanically and clinically equivalent. Viable graft choices include ipsilateral palmaris longus tendon autograft, gracilis or semitendinosus autograft, and allograft. Clinical studies report excellent outcomes of UCLR for both recreational and elite level athletes with regard to return to sport and postoperative performance. Complications, although rare, include graft rerupture or attenuation, ulnar nerve symptoms, stiffness, pain, and/or weakness leading to decreased performance.

Conclusion:

Injuries to the UCL have become commonplace among pitchers. Nonoperative treatment should be attempted, but the limited studies have not shown promising results. Operative treatment can be performed with several techniques, with retrospective studies showing promising results. Complications include ulnar neuropathy as well as failure to return to sport. Detailed preoperative planning, meticulous surgical technique, and a comprehensive rehabilitation program are essential components to achieving a satisfactory result.