Ulnar Collateral Ligament Repair of the Elbow-Biomechanics, Indications, and Outcomes

Augmented Ulnar Collateral Ligament Repair With Structural Bioinductive Scaffold: A Biomechanical Study

BACKGROUND

Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair.

PURPOSE/HYPOTHESIS

This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight cadaveric elbow specimens-from midforearm to midhumerus-were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL-with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected-distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing.

RESULTS

The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold-augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first.

CONCLUSION

UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted.

CLINICAL RELEVANCE

As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.

ChatGPT Can Offer Satisfactory Responses to Common Patient Questions Regarding Elbow Ulnar Collateral Ligament Reconstruction

Purpose

To determine whether ChatGPT effectively responds to 10 commonly asked questions concerning ulnar collateral ligament (UCL) reconstruction.

Methods

A comprehensive list of 90 UCL reconstruction questions was initially created, with a final set of 10 "most commonly asked" questions ultimately selected. Questions were presented to ChatGPT and its response was documented. Responses were evaluated independently by 3 authors using an evidence-based methodology, resulting in a grading system categorized as follows: (1) excellent response not requiring clarification; (2) satisfactory requiring minimal clarification; (3) satisfactory requiring moderate clarification; and (4) unsatisfactory requiring substantial clarification.

Results

Six of 10 ten responses were rated as "excellent" or "satisfactory." Of those 6 responses, 2 were determined to be "excellent response not requiring clarification," 3 were "satisfactory requiring minimal clarification," and 1 was "satisfactory requiring moderate clarification." Four questions encompassing inquiries about "What are the potential risks of UCL reconstruction surgery?" "Which type of graft should be used for my UCL reconstruction?" and "Should I have UCL reconstruction or repair?" were rated as "unsatisfactory requiring substantial clarification."

Conclusions

ChatGPT exhibited the potential to improve a patient's basic understanding of UCL reconstruction and provided responses that were deemed satisfactory to excellent for 60% of the most commonly asked questions. For the other 40% of questions, ChatGPT gave unsatisfactory responses, primarily due to a lack of relevant details or the need for further explanation.

Clinical Relevance

ChatGPT can assist in patient education regarding UCL reconstruction; however, its ability to appropriately answer more complex questions remains to be an area of skepticism and future improvement.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review

PURPOSE

To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation.

METHODS

A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications.

RESULTS

In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%).

CONCLUSIONS

Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes.

CLINICAL RELEVANCE

UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.

Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair

Purpose

To evaluate the incidence of early postoperative complications and revision surgery in patients who underwent primary medial ulnar collateral ligament (MUCL) repair with minimum of 2-year follow-up.

Methods

A retrospective review of a national insurance database was conducted to identify patients with MUCL injuries who underwent primary MUCL repair between 2015 to 2020 with minimum 2-year follow-up. Patients >40 years of age and those who had concomitant elbow fractures or dislocations, lateral UCL injures, medial epicondylitis, elbow arthritis, or a history of previous elbow injury/surgery were excluded. The number of patients who underwent a concomitant ulnar nerve procedure (transposition or decompression) during the primary MUCL repair was recorded. Complications within 90 days of surgery and the incidence and timing of subsequent ipsilateral ulnar nerve surgery or revision MUCL surgery were assessed.

Results

A total of 313 patients (63.6% male) were included. The mean age was 20.3 ± 6.9 years, and mean follow-up was 3.7 ± 1.3 years. Concomitant ulnar nerve transposition or decompression was performed in 34.2% (N = 107). The early postoperative complication rate was 7.3% (N = 23). The most common complication was ulnar neuropathy (5.8%, N = 18). Wound complications, elbow stiffness, and medial epicondyle fractures were much less common (N = 5). Sixteen of 18 (88.9%) patients with postoperative ulnar neuropathy underwent transposition or decompression at the time of primary repair. Of these 18 patients, 5 (27.8%) underwent a subsequent ulnar nerve surgery (1 primary and 4 secondary), with the majority occurring within 6 months. The incidence of revision MUCL surgery was low (1.0%, N=3), with all 3 patients undergoing MUCL reconstruction.

Conclusion

There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. All 3 (1.0%) MUCL revisions underwent reconstruction.

Level of Evidence

Level IV, therapeutic case series.

Martial Arts: Orthopaedic Injuries and Related Biomechanics

Martial arts are various systems of combat skills encompassing striking and grappling. Many styles have evolved into modern sports, and some have been included in the Olympics. The physicality of these can predispose practitioners to musculoskeletal injuries, such as anterior cruciate ligament ruptures; patellar, shoulder, or elbow instabilities; extremity fractures; and hand and spine injuries, which have been studied both clinically and biomechanically. The most common injury related to longer time loss from participation is an anterior cruciate ligament rupture. Higher injury incidence is associated with a higher level of experience and competition. Orthopaedic management of martial arts injuries should reflect the specific needs of each martial artist and the biomechanics of motions common to each style. Full-contact practitioners may benefit from broader surgical indications and special attention to the choice and positioning of implants; nonsurgical treatment may be appropriate for certain pediatric or noncontact practitioners. Approximately 60% of martial artists can return to the preinjury level of participation after a major injury. Injury prevention and rehabilitation programs should optimize neuromotor control and core engagement to ensure proper body mechanics. Gradual incorporation of martial arts movement into the postoperative physical therapy curriculum can benefit physical progress and help gain confidence toward full participation.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Results in Good Clinical Results, a Return-to-Play Rate Between 67% and 93%, and a Postoperative Complication Rate Up to 11.9%: A Systematic Review

Purpose

To review the Kerlan-Jobe Orthopaedic Clinic (KJOC) scores, return-to-play rates, and complications after ulnar collateral ligament (UCL) repair with suture augmentation.

Methods

A literature search of the PubMed and Scopus databases was conducted on February 17, 2023, using the terms "ulnar collateral ligament," "repair," "internal brace," and "suture augmentation." The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol and included 4 articles published from 2019 to 2022. The inclusion criteria included studies reporting outcomes, return-to-play rates, and/or complications after UCL repair with suture augmentation. The exclusion criteria consisted of non-English language studies, case reports, cadaveric studies, animal studies, letters to the editor, studies with overlapping cohorts, and review articles. The risk of bias was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

Results

The final analysis included 4 studies with 510 patients (457 male and 53 female patients), ranging in age between 17.8 and 27.5 years, treated with repair and suture augmentation for UCL tears. In this review, we found a mean postoperative KJOC score ranging from 87.9 to 92.6. The overall rate of return to play at the preinjury level or at a higher level than the preinjury level ranged from 67% to 93%; the mean time to return to play ranged from 6.7 to 17.6 months. The postoperative complication rate in this review ranged from 0% to 11.9%. Among the complications, the most common were ulnar nerve paresthesia (range, 0%-8.2%) and postoperative medial elbow pain (range, 0%-3.1%). Overall, the reoperation rate ranged from 0% to 3.4%. No reruptures were reported.

Conclusions

UCL repair with the use of suture augmentation results in postoperative KJOC scores ranging from 87.9 to 92.6, a return-to-play rate between 67% and 93%, and a postoperative complication rate up to 11.9%.

Level of Evidence

Level IV, systematic review of Level IV studies.

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.

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

Background

Ulnar collateral ligament (UCL) reconstruction has received a unique level of attention in the press and social media. There has also been an increasing use of the internet by patients to seek medical information. Concern exists regarding the quality and comprehensibility of online information when used for patient education.

Purpose

To evaluate the quality and comprehensibility of the most-viewed YouTube videos related to the diagnosis and management of UCL injuries. Based on our new evidence-based scoring rubrics, we hypothesized that the quality and comprehensibility of these videos would be poor.

Study Design

Cross-sectional study.

Methods

The YouTube platform was searched on September 7, 2021, with the terms "UCL injury," "ulnar collateral ligament injury," "UCL surgery," "ulnar collateral ligament surgery," and "Tommy John surgery," and the 50 most-viewed videos from each search were compiled, yielding 250 videos. After removal of duplicates and application of exclusion criteria, the 100 most-viewed videos remained. Basic attributes, including duration of video and number of views, were recorded. Each video was then analyzed by 2 independent reviewers and evaluated for 4 key parameters (quality of diagnostic content [QAR-D], quality of treatment content [QAR-T], presence of inaccurate information, and comprehensibility) and graded on a novel scale from 1 to 4 (4 being the most appropriate for patient education).

Results

The mean QAR-D was 4.83 ± 3.41 (fair quality), and the mean QAR-T was 2.76 ± 3.26 (poor quality). Physician-led educational videos had both the highest mean QAR-D (6.37) and the highest mean QAR-T (4.34). No correlation was observed between video quality and views/likes. A total of 12 videos included ≥1 inaccuracy. The mean comprehensibility score was 2.66 ± 1.12, with 39 videos falling below the acceptable comprehensibility threshold (score <3).

Conclusion

The overall quality of UCL injury-related YouTube content was low. In addition, the absence of correlation between video quality and views/likes suggests that patients are not preferentially utilizing the limited high-quality content that does exist on the YouTube platform. In addition, inaccurate videos were prevalent (12%), and almost half of all videos were deemed inappropriate for patient education in terms of comprehensibility, as defined by our comprehensibility parameter.

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

Background

The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges.

Methods

A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups.

Results

A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N = 25) to 2019 (N = 315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P < .001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P = .05). There were no differences among commonly associated procedures including ulnar nerve surgery (P = .217), elbow arthroscopy (P = .092), and platelet-rich plasma injection (P = .837) with no differences in patient-level charges at any time point (P = .47).

Conclusion

While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

Medial Ulnar Collateral Ligament Injuries in Contact Athletes

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.

Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management

Ulnar collateral ligament (UCL) injuries of the elbow are common in overhead throwing athletes. With throwing, the elbow experiences substantial valgus stress and repetitive microtrauma can lead to injury. Increasing rates of injury among both youth and professional throwers has resulted in a "UCL epidemic." Ulnar collateral ligament reconstruction ("Tommy John Surgery") became a part of the public consciousness after Tommy John returned to professional baseball after a UCL reconstruction with Dr Frank Jobe for what was once considered a career-ending injury. Partial tears and some athletes with complete UCL injuries can be managed without surgery. Since the introduction of UCL reconstruction, technical modifications have aimed to decrease complications and increase return-to-play rates. Ulnar collateral ligament repair has reemerged as a potential surgical option for some throwers. Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries.