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Buchanan TR, Hones KM, Hao KA, Kamarajugadda S, Portnoff B, Wright JO, King JJ, Wright TW, Kim J, Schoch BS, Roach RP, Aibinder WR. Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years. Sports Health 2024:19417381241249125. [PMID: 38702939 DOI: 10.1177/19417381241249125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
CONTEXT Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management. OBJECTIVE This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation. DATA SOURCES Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022. STUDY SELECTION Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing. RESULTS Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores. CONCLUSION Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.
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Affiliation(s)
| | - Keegan M Hones
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, Florida
| | | | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Jonathan O Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Jongmin Kim
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Ryan P Roach
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Hones KM, Simcox T, Hao KA, Portnoff B, Buchanan TR, Kamarajugadda S, Kim J, Wright JO, King JJ, Wright TW, Schoch BS, Aibinder WR. Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:1185-1199. [PMID: 38072032 DOI: 10.1016/j.jse.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.
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Affiliation(s)
- Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Trevor Simcox
- Department of Orthopaedic Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | | | | | - Jongmin Kim
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.
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Peebles LA, Blackwood NO, Verma A, O'Brien MJ, Lintner DM, Kraeutler MJ. 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. Arthroscopy 2024:S0749-8063(24)00268-8. [PMID: 38593928 DOI: 10.1016/j.arthro.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Liam A Peebles
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
| | | | - Arjun Verma
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Michael J O'Brien
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - David M Lintner
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Matthew J Kraeutler
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
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Inagaki K, Ochiai N, Hashimoto E, Hattori F, Hiraoka Y, Ise S, Shimada Y, Ohtori S. Biomechanical Comparison of Stability and Strength After Ulnar Collateral Ligament Reconstruction With Suture Anchor Fixation Versus Bone Tunnels. Orthop J Sports Med 2023; 11:23259671231196135. [PMID: 37693807 PMCID: PMC10492499 DOI: 10.1177/23259671231196135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Ulnar collateral ligament (UCL) injuries occur frequently in baseball players, and UCL reconstruction is performed when nonoperative treatment fails. Purpose To compare a novel all-suture anchor method of UCL reconstruction with a method using bone tunnels (Ito method) by investigating the displacement against valgus torque and the failure strength. Study Design Controlled laboratory study. Methods Eight fresh-frozen cadaveric upper extremities (mean age, 82.0 years) were utilized in this study. To evaluate the displacement against valgus torque, the valgus stability test was performed for 4 anterior oblique ligament (AOL) conditions: intact AOL, resected AOL, reconstructed using the anchor method, and reconstructed using the Ito method. The load-to-failure test was performed to evaluate the failure strength of the anchor and Ito methods. Displacement against valgus load was compared between conditions using the repeated-measures 2-way analysis of variance with Bonferroni post hoc test, and failure strength between the anchor and Ito methods was compared using the unpaired t test. Results Displacements of the intact AOL and anchor method were significantly greater than those of the resected AOL at both 60° and 90° of flexion (intact AOL: P = .005 and P < .001, respectively; and anchor method: P = .024 and P < .001, respectively). The displacement of the Ito method at 90° of flexion was significantly greater than that of the resected AOL (P = .003), but no significant difference was observed at 60° of flexion (P = .109). There were no significant differences in displacement between the anchor and Ito methods at any flexion angle, nor was there a significant difference in failure torque between the anchor and Ito methods (16.3 ± 3.1 vs 17.6 ± 2.3 N·m, respectively; P = .537). Conclusion The displacement and failure strength against a valgus load after UCL reconstruction using a suture anchor on the ulnar side were equal to those using bone tunnels. Clinical Relevance UCL reconstruction using a suture anchor on the ulnar side is simpler and less invasive than using bone tunnels, with similar outcomes.
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Affiliation(s)
- Kenta Inagaki
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Nobuyasu Ochiai
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Eiko Hashimoto
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Fumiya Hattori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yu Hiraoka
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Shohei Ise
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yohei Shimada
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
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Fathi A, Haratian A, Treloar J, Bolia IK, Hasan LK, Weber AE, Petrigliano FA. Pain Is the Most Frequently Cited Reason Athletes Fail to Return to Sport After Ulnar Collateral Ligament Surgery: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10:23259671221128257. [PMID: 36313005 PMCID: PMC9608054 DOI: 10.1177/23259671221128257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background No previous systematic review to our knowledge has examined the reasons that athletes fail to return to sport (RTS) after ulnar collateral ligament (UCL) surgery. Purpose To report the rate of failure to RTS after UCL surgery and identify reasons that preclude an athlete's ability to successfully RTS. Study Design Systematic review; Level of evidence, 4. Methods This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Scopus, and SPORTDiscus databases for studies on athletes who underwent either UCL reconstruction or repair that reported RTS rates and identified reasons for failure to RTS. Data were collected on the number of athletes included, average age, sport played, operative technique, average follow-up, rate of failure to RTS, and reasons for failure to return. A random-effects model was used to conduct the meta-analysis. Results Included were 26 studies reporting on 1019 athletes. Primary or revision UCL reconstruction was performed in 913 patients (89.6%), while the remaining 106 patients (10.4%) underwent UCL repair. The pooled rate of failure to RTS after UCL reconstruction or repair was calculated to be 11.4% (95% CI, 8.4-14.7). A significantly higher estimated proportion of athletes failed to return because of elbow-related reasons compared with non-elbow-related reasons (55.3% vs 40.6%; P = .0352). Persistent pain (29/103; 28.2%) was the most common reason for failure to return, followed by elbow limitations and other unspecified elbow problems (19/103; 18.4%). There was moderate evidence for publication bias and study heterogeneity across the included studies. Conclusion This meta-analysis estimated the rate of failure to RTS after UCL surgery as 11.4%, with the majority of athletes unable to return because of elbow pain. Future studies reporting outcomes and providing details as to why athletes are unable to RTS can better inform sport surgeons on factors precluding RTS and can guide clinical practice to better help athletes achieve their postoperative goals.
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Affiliation(s)
- Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Joshua Treloar
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Laith K. Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA.,Frank A. Petrigliano, MD, Keck Medicine of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA ()
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Kemler BR, Rao S, Willier DP, Jack RA, Erickson BJ, Cohen SB, Ciccotti MG. Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review. Am J Sports Med 2022; 50:3112-3120. [PMID: 34494905 DOI: 10.1177/03635465211033994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.
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Affiliation(s)
- Bryson R Kemler
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | | | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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Liu W, Xiong H, Chen S, Zhang J, Wang W, Qian Y, Fan C. Biomechanical Evaluation of a Low-Invasive Elbow Medial Collateral Ligament Reconstruction Technique With Fascia and Tendon Patches. Front Bioeng Biotechnol 2022; 10:831545. [PMID: 35392401 PMCID: PMC8980741 DOI: 10.3389/fbioe.2022.831545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Injury to the medial collateral ligament (MCL) of the elbow has become increasingly common in sports, and the elbow is prone to contracture and ossification in trauma. Effective reconstruction of the MCL with reduction of irritation to the elbow has rarely been reported. This study introduces a minimally invasive elbow MCL reconstruction technique and evaluates the valgus stability. Methods: Eight fresh-frozen elbow specimens underwent reconstruction of the anterior bundle of the MCL (AMCL) first with the flexor carpi ulnaris fascia patches, followed by reconstruction of the posterior bundle of the MCL (PMCL) with the triceps tendon patches. The valgus angles of each specimen were examined in three stages as follows: intact MCL, reconstruction of the AMCL alone, and reconstruction of the MCL (including AMCL and PMCL). Finally, specimens were loaded to failure, and failure modes were recorded. Results: AMCL reconstruction alone had similar valgus stability at all testing angles (p = 0.080, 30° flexion; p = 0.064, 60° flexion; p = 0.151, 90° flexion; p = 0.283, 120° flexion) compared with the intact MCL, as did MCL reconstruction (p = 0.951, 30° flexion; p = 0.739, 60° flexion; p = 0.841, 90° flexion; p = 0.538, 120° flexion). More importantly, a significant difference existed between the MCL reconstruction and the AMCL reconstruction alone at 30° flexion (p = 0.043) and 60° flexion (p = 0.013) but not at the 90° flexion (p = 0.369) and 120° flexion (p = 0.879). The mean maximum failure torque of MCL reconstruction was 24.02 Nm at 90° elbow flexion. Conclusion: Both AMCL reconstruction alone and MCL reconstruction provided valgus stability comparable with the native MCL, and importantly, MCL reconstruction provided more valgus stability than AMCL reconstruction alone at 30° flexion and 60° flexion of the elbow. Therefore, the new MCL reconstruction technique might be a useful guide for the treatment of elbow MCL injuries or deficiencies.
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Affiliation(s)
- Wenjun Liu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital South Campus, Shanghai, China
| | - Hao Xiong
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Jingwei Zhang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital South Campus, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
| | - Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
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Hadley CJ, Rao S, Erickson BJ, Cohen SB, Dodson CC, Ciccotti MG, Romeo AA. Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes. J Shoulder Elbow Surg 2022; 31:488-494. [PMID: 34687920 DOI: 10.1016/j.jse.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers. PURPOSE To report outcomes after UCLR in javelin throwers. HYPOTHESIS UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports. METHODS All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications. RESULTS Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery. CONCLUSION UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.
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Affiliation(s)
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | | | | | | | - Anthony A Romeo
- Shoulder, Elbow, Sports Surgery, Dupage Medical Group, Downers Grove, IL, USA
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Looney AM, Bovill JD, Huffman SS, Najarian RG. Routine diagnostic arthroscopy with elbow ulnar collateral ligament reconstruction does not reduce the need for future valgus extension overload-related surgeries: a systematic review and meta-analysis. J Shoulder Elbow Surg 2022; 31:e22-e36. [PMID: 34478864 DOI: 10.1016/j.jse.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Valgus extension overload syndrome (VEOS) most commonly affects overhead athletes and consists of a constellation of conditions involving the medial, posterior, and lateral elbow, with the most widely discussed being ulnar collateral ligament (UCL) injuries. Many athletes with UCL tears also have findings consistent with other VEOS conditions, though these are not consistently symptomatic. Given the high rate of concomitant pathology, many authors have recommended performing arthroscopy at the time of UCL reconstruction (UCLR) to diagnose and address concomitant VEOS pathology; however, it is not known if this practice actually leads to a reduction in subsequent surgeries for VEOS conditions following index UCLR. The purpose of this systematic review and meta-analysis was to determine if performing routine diagnostic arthroscopy (RDA) in patients undergoing UCLR was associated with a lower incidence of future VEOS-related surgery. METHODS This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the primary outcome of interest being the likelihood of needing future surgery to address VEOS conditions with or without RDA at the time of index UCLR. The proportion and incidence rate of subsequent VEOS-related surgeries following UCLR with and without RDA were compared in mixed effects models. RESULTS There were 25 eligible studies from an initial 1335 systematically identified articles, with results for 2118 UCLR cases. Among these, there were a total of 94 reported VEOS-related surgeries. The proportion of subsequent VEOS-related surgeries was lower when UCLR was performed with RDA (0.40%, 95% CI 0.00%-3.51%) than without (1.16%, 95% CI 0.03%-3.25%), but the difference was not significant (P = .584). The incidence rate of VEOS-related surgeries was 0.16 (95% CI 0.00-0.95) per 100 person-years with RDA and 0.14 (95% CI 0.00-0.55) per 100 person-years without RDA (P = .942). CONCLUSION RDA preceding UCLR does not significantly reduce the proportion or rate of subsequent surgery for other VEOS conditions. There has been a decrease in RDA utilization with UCLR over time for athletes with torn/incompetent UCLs but otherwise no known symptomatic VEOS conditions, and this trend appears to be justified based on these findings.
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Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA.
| | - John D Bovill
- School of Medicine, Georgetown University, Washington, DC, USA
| | | | - Robert G Najarian
- Department of Orthopaedic Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
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10
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Douoguih WA, Day J, Bahrun EA, Bodendorfer BM, Brandt C, Looney A. Postoperative Rehabilitation of Ulnar Collateral Ligament Reconstruction: A Systematic Review. Sports Med Arthrosc Rev 2021; 29:e9-e17. [PMID: 33972489 DOI: 10.1097/jsa.0000000000000318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of ulnar collateral ligament injuries has increased over the past few decades with greater participation in overhead throwing sports; however, optimal postoperative management following surgery remains unclear. This systematic review summarizes the latest evidence, on postoperative rehabilitation protocols for patients undergoing ulnar collateral ligament reconstruction (UCLR). Studies published in the English language from the year 2000 to 2019 with a level 1 to 4 grade of evidence and examined rehabilitation protocols following UCLR were eligible for inclusion. A multidatabase search was conducted. Two blinded reviewers screened and graded articles for inclusion and a third independent reviewer resolved any conflicts. Ten of the original 139 studies identified were used for analysis. Surgical techniques as well as rehabilitation protocols varied across studies. Analysis gave strong evidence that a 4-phase postoperative rehabilitation protocol utilizing milestone-based goals is effective in returning athletes back to preinjury levels of activity and sport within 1 year following UCLR.
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Affiliation(s)
- Wiemi A Douoguih
- Department of Orthopaedic Surgery, MedStar Washington Hospital Center
| | | | | | - Blake M Bodendorfer
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC
| | | | - Austin Looney
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC
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11
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Davey MS, Hurley ET, Gaafar M, Galbraith JG, Mullett H, Pauzenberger L. Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review. J ISAKOS 2021; 6:290-294. [PMID: 34001506 DOI: 10.1136/jisakos-2021-000614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/21/2021] [Accepted: 04/08/2021] [Indexed: 11/03/2022]
Abstract
IMPORTANCE Tears of the ulnar collateral ligament (UCL) of the elbow occur predominantly as an overuse injury, most commonly affecting throwing athletes, particularly baseball players. UCL reconstruction (UCLR) has been described as an effective treatment modality in the short term. OBJECTIVE The purpose of this study was to systematically review the evidence in the literature to ascertain the clinical outcomes, complication and revision rates in baseball players following UCLR of the elbow at a minimum of 48 months of follow-up. EVIDENCE REVIEW Two independent reviewers performed a search of the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, PubMed and Scopus databases. Clinical studies were included if they reported outcomes of baseball players at a minimum of 48 months following UCLR. FINDINGS Our review included 8 studies including 1104 baseball players (1105 elbows) at mean 69.9 months (48-205) following UCLR. The majority of baseball players were pitchers (92.3%), with a mean age of 22.2 years (13-42). At final follow-up, the overall return to play (RTP) was 95.3%%, with 85.3% returning at pre-injury level. In addition, the mean reported Conway-Jobe score was 86.8%, the revision rate was 6.0% with postoperative neuropathy reported in 2.4% of patients. A total of 479 (43.4%) were professional baseball players, with an overall RTP rate of 97.5% and 82.3% managing to RTP at their pre-injury level. The mean number of career years following UCLR was 4.7 years (0-22). CONCLUSION AND RELEVANCE UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. In addition, high rates of RTP at pre-injury level and career longevity were reported by baseball players following UCLR. LEVEL OF EVIDENCE Level IV; Systematic Review.
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Affiliation(s)
- Martin S Davey
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland .,Department of Trauma & Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Mohamed Gaafar
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - John G Galbraith
- Department of Trauma & Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Hannan Mullett
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Leo Pauzenberger
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
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12
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Yoshida M, Takenaga T, Takeuchi S, Takaba K, Tsuchiya A, Fukuyoshi M, Nakagawa H, Matsumoto Y, Saito M, Futamura H, Futamura R, Murakami H, Sugimoto K. Ulnar Collateral Ligament Reconstruction With the Modified Jobe Technique in Baseball Pitchers. Orthop J Sports Med 2021; 9:2325967121998339. [PMID: 35146025 PMCID: PMC8822039 DOI: 10.1177/2325967121998339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/13/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Tearing and insufficiency of the ulnar collateral ligament (UCL) of the elbow result in valgus instability, which can lead to pain while throwing and decline in performance in overhead athletes. Purpose: To assess the clinical results of a modified UCL reconstruction technique using 1 bone hole in the ulna and 1 bone tunnel in the humerus in baseball players. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria were medial elbow pain preventing effective playing, clinically medial elbow laxity, and magnetic resonance imaging results consistent with UCL injury. Patients who were engaged in other sports and in other positions in baseball except pitchers were excluded from this study. Our modified Tommy John procedure was performed via a muscle-splitting approach and an original single-bone-tunnel technique, using a suture anchor. After a minimum of 24 months, patients were evaluated using the Conway scale and the Timmerman-Andrews score. Results: Of 31 patients, 20 baseball pitchers (20 male: 5 high school, 5 collegiate, 8 nonprofessional, and 2 professional pitchers) were reviewed. The mean patient age at the time of operation was 21.9 years, and the mean postoperative follow-up period was 35.1 months (range, 24-66 months). The mean Timmerman-Andrews subjective score improved significantly from pre- to postoperatively (from 68.3 to 98.3; P < .05); the objective score also improved significantly (from 81.1 to 96.4; P = .01). No complications were detected at the latest follow-up. Overall, 19 patients were able to return to their preinjury level of sports or higher. Conclusion: UCL reconstruction with 1 bone hole in the ulna and 1 bone tunnel in the humerus demonstrated satisfactory results in baseball pitchers. Our modified technique was safe and achieved satisfactory clinical results, with a 95% rate of return to sports.
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Affiliation(s)
- Masahito Yoshida
- Department of Musculoskeletal Sports Medicine, Research and Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tetsuya Takenaga
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Satoshi Takeuchi
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Keishi Takaba
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Atsushi Tsuchiya
- Arthroscopy & Sports Medicine Center, Meitetsu Hospital, Nagoya, Japan
| | | | | | | | | | | | | | - Hideki Murakami
- Department of Musculoskeletal Sports Medicine, Research and Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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13
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Mirzayan R, Benvegnu N, Sidell M, Acevedo DC, DeWitt DO, Lowe N, Singh A. Functional outcomes of ulnar collateral ligament reconstruction with a novel double suspensory fixation. J Shoulder Elbow Surg 2020; 29:1530-1537. [PMID: 32713464 DOI: 10.1016/j.jse.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar collateral ligament reconstruction (UCLR) has allowed the return of overhead athletes to throwing sports. We describe a new double suspensory (DS) technique using a single tunnel in the ulna and humerus, achieving fixation with adjustable loop buttons. METHODS Inclusion criteria included skeletally mature baseball players with clinical and magnetic resonance imaging diagnosis of UCL insufficiency who failed a trial of structured nonoperative treatment. A total of 36 baseball players underwent DS UCLR, between 2011 and 2017, by 1 surgeon with minimum 2-year follow-up. The graft was fixated with an adjustable button loop on the humeral side and a tension slide technique with a button on the ulnar side. Pre- and postoperative Kerlan-Jobe Orthopaedic Clinic and Single Assessment Numerical Evaluation and postoperative Conway scores were obtained. RESULTS The mean age was 19.8 ± 4.6 years (range, 14-35 years). All were male. Mean years played before surgery was 14.3 ± 4.6 years (range, 8-28 years). There were 32 (89%) pitchers and 4 (11%) position players. There were 13 (36%) high school, 20 (55%) college, 2 (6%) minor league, and 1 (3%) adult league athletes. The mean follow-up was 55.3 ± 23.7 months (range, 26-97 months). There was significant improvement in Kerlan-Jobe Orthopaedic Clinic (33.2 ± 19.9 to 89.7 ± 15.1, P < .0001) and Single Assessment Numerical Evaluation (20.7 ± 16.7 to 93.6 ± 11.9, P < .0001) scores. Using Conway scoring, 25 (69%) had excellent, 5 (14%) good, 3 (8%) fair, and 3 (8%) poor scores. Mean return to play was 9 ± 1.5 months (range, 6-16 months). Only 1 (3%) athlete required a revision surgery and ultimately returned to play and 1 (3%) hardware removal. None developed ulnar nerve symptoms. CONCLUSION DS fixation for UCLR in baseball players can lead to excellent clinical results and early return to play.
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Affiliation(s)
- Raffy Mirzayan
- Department of Orthopaedics, Kaiser Permanente Southern California, Baldwin Park, CA, USA.
| | - Neilen Benvegnu
- Department of Orthopaedics, USC Keck School of Medicine, Los Angeles, CA, USA
| | - Margo Sidell
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Daniel C Acevedo
- Department of Orthopaedics, Kaiser Permanente Southern California, Panorama City, CA, USA
| | - David O DeWitt
- Department of Orthopaedics, Kaiser Permanente Southern California, Baldwin Park, CA, USA
| | - Nikko Lowe
- Department of Orthopaedics, Kaiser Permanente Southern California, Baldwin Park, CA, USA
| | - Anshuman Singh
- Department of Orthopaedics, Kaiser Permanente Southern California, San Diego, CA, USA
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14
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Lawton CD, Lamplot JD, Wright-Chisem JI, James EW, Camp CL, Dines JS. State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes. Curr Rev Musculoskelet Med 2020; 13:338-348. [PMID: 32323247 PMCID: PMC7251011 DOI: 10.1007/s12178-020-09621-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Cort D Lawton
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Joseph D Lamplot
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Joshua I Wright-Chisem
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Evan W James
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Christopher L Camp
- Division of Sports Medicine, Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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15
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Jensen AR, LaPrade MD, Turner TW, Dines JS, Camp CL. The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020. Curr Rev Musculoskelet Med 2020; 13:349-360. [PMID: 32314245 PMCID: PMC7251039 DOI: 10.1007/s12178-020-09618-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe's initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted. RECENT FINDINGS The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80-95%), the mean time to return to play (typically 12-18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.
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Affiliation(s)
- Andrew R. Jensen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN USA
| | | | - Travis W. Turner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN USA
| | - Joshua S. Dines
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY USA
| | - Christopher L. Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street, Rochester, MN USA
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16
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Biz C, Crimì A, Belluzzi E, Maschio N, Baracco R, Volpin A, Ruggieri P. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review. Orthop Surg 2019; 11:974-984. [PMID: 31773896 PMCID: PMC6904592 DOI: 10.1111/os.12571] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 12/24/2022] Open
Abstract
Objective Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions. Methods A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC). Results A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction. Conclusions There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.
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Affiliation(s)
- Carlo Biz
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Alberto Crimì
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Elisa Belluzzi
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.,Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Nicola Maschio
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Riccardo Baracco
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Andrea Volpin
- Trauma and Orthopaedic Department, Royal Derby Hospital NHS Foundation Trust, Derby, UK
| | - Pietro Ruggieri
- Orthopaedic Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
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17
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Abstract
PURPOSE OF REVIEW Primarily reported in the overhead throwing athlete, ulnar collateral ligament (UCL) injuries have been extensively studied since Dr. Frank Jobe first described his technique for ulnar collateral ligament reconstruction on professional baseball pitcher Tommy John. While the framework for our understanding of UCL injury was initially established studying the repetitive valgus loading of the throwers' elbow, other sport-related activities in non-throwing athletes can impart similar valgus stress on the medial elbow placing the UCL at risk for injury. The purpose of this review is to evaluate the current literature on UCL injury specifically in the non-throwing athlete. RECENT FINDINGS In the four decades since Dr. Jobe's seminal description of UCL reconstruction, an abundance of literature has been published on UCL injury in the throwing athlete. The evidence evaluating the UCL specifically in the non-throwing athlete, however, is quite scarce. Several small retrospective studies have demonstrated good results with high rates of return to play with focused rehabilitation and non-operative management in non-throwing athletes. Recent evidence has also demonstrated that surgical repair and/or reconstruction of the UCL in this population can produce good outcomes. The level of evidence of these published studies is low and consists primarily of case series without control groups. Further investigation is warranted to determine the optimal treatment algorithm for UCL injury in the non-throwing athlete.
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Affiliation(s)
- Nicholas Ramos
- Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA, 90045, USA.
| | - Orr Limpisvasti
- Kerlan Jobe Institute, 6801 Park Terrace, Los Angeles, CA, 90045, USA
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18
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Somerson JS, Petersen JP, Neradilek MB, Cizik AM, Gee AO. Complications and Outcomes After Medial Ulnar Collateral Ligament Reconstruction: A Meta-Regression and Systematic Review. JBJS Rev 2019; 6:e4. [PMID: 29738408 DOI: 10.2106/jbjs.rvw.17.00138] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Evidence is limited regarding the complications and outcomes after medial ulnar collateral ligament (UCL) reconstruction. The published data regarding this procedure are composed predominantly of small Level-III and IV retrospective studies for which meta-analysis is not generally useful. Meta-regression is an alternative technique to identify variables across multiple publications that have an effect on published outcomes and complication rates. METHODS We performed a systematic search of published literature for outcomes after UCL reconstruction. A random effects meta-regression model was constructed to identify the association of study characteristics with outcome proportions. Sensitivity analyses were performed to assess the impact of influential studies on the results. RESULTS Fourteen studies (median sample size, 26 patients; range, 10 to 743 patients) were included in the systematic review and meta-regression. These studies included a total of 1,177 patients with a reported Conway outcome rating (a measure of a patient's return to play). The majority of patients (mean, 83.2%) achieved an excellent Conway rating. Studies involving the docking technique were more likely to have a higher percentage of patients with an excellent outcome (14% risk difference compared with the figure-of-8 technique, p = 0.002) and lower reported rates of ulnar neurapraxia (Spearman correlation = -0.83). A lower reported rate of ulnar neurapraxia was strongly associated with the likelihood of an excellent (p = 0.01) or good or excellent (p = 0.001) Conway outcome rating. CONCLUSIONS Despite substantial heterogeneity among study outcomes, studies that involved a docking technique and that had lower reported rates of ulnar neurapraxia were associated with greater percentages of excellent or good-to-excellent reported Conway outcome ratings. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - John P Petersen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | | | - Amy M Cizik
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Albert O Gee
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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19
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Clain JB, Vitale MA, Ahmad CS, Ruchelsman DE. Ulnar Nerve Complications After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review. Am J Sports Med 2019; 47:1263-1269. [PMID: 29683338 DOI: 10.1177/0363546518765139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. PURPOSE The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed. RESULTS Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). CONCLUSION Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.
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Affiliation(s)
- Jason B Clain
- Division of Plastic Surgery, Harvard Integrated Plastic Surgery Program, Harvard Medical School, Boston, Massachussetts, USA
| | - Mark A Vitale
- ONS Foundation for Clinical Research and Education, ONS, P.C., Greenwich, Connecticut, USA.,Greenwich Hospital, Yale-New Haven Health, Greenwich, Connecticut, USA
| | - Christopher S Ahmad
- Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, New York, USA
| | - David E Ruchelsman
- Newton-Wellesley Hospital, Newton, Massachussetts, USA.,Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, Massachussetts, USA.,Hand Surgery Research and Education Foundation, Newton, Massachussetts, USA
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Donohue BF, Lubitz MG, Kremchek TE. Elbow Ulnar Collateral Ligament Reconstruction Using the Novel Docking Plus Technique in 324 Athletes. SPORTS MEDICINE - OPEN 2019; 5:3. [PMID: 30649654 PMCID: PMC6335231 DOI: 10.1186/s40798-018-0174-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/02/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND This retrospective case series examined 324 athletes who received elbow ulnar collateral ligament (UCL) reconstruction by a single surgeon in a private practice over a 9-year period. The novel Docking Plus technique for elbow UCL reconstruction in 324 athletes provided good or excellent Conway score results in 88% of patients. The preponderance of previous studies examining UCL reconstruction outcomes were performed by surgeons at one of only three institutions (Andrews Institute, Hospital for Special Surgery, Kerlan Jobe Orthopedic Clinic). METHODS Patients undergoing UCL reconstruction from November 2005 to December 2014 were identified and contacted with a mailed survey and phone call. These patients were given a subjective 19 question survey assessing their outcomes from surgery. RESULTS The participants who responded to our survey were 90% male and 77% baseball players, 73% of which were pitchers. Of the baseball players who responded, 51.9% were in high school at the time of their surgery, 37% college, 6.5% minor leagues, and 2.2% in Major League Baseball. After surgery, 36% of survey responders returned to a higher level of competition than previously. For example, a high school athlete who had UCL reconstruction and went on to pitch in college. Further, 45% returned to the same level, and 7% returned to a lower level. Subjective "satisfaction," was reported in 92% of responders and 97.2% reported that, "having surgery was a good idea." Symptom onset in the responding athletes was 58.9% sudden, and 41.1% gradual. Overall, 90.9% of respondents returned to play in less than 1.5 years while 6.3% never were able to return. Re-tear occurred in 2.5% of patients, while 8.8% had subjective nerve dysfunction for at least 3 months following surgery. CONCLUSION The Docking Plus technique can produce excellent subjective and objective results in athletes. Further study is warranted to see the effects of this procedure in other settings and determine which method of reconstruction or repair is superior.
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Affiliation(s)
| | - Marc G. Lubitz
- UMass Medical School, 55 Lake Ave N, Worcester, MA 01655 USA
| | - Timothy E. Kremchek
- Beacon Orthopeadics and Sports Medicine, 500 E Business Way, Cincinnati, OH 45241 USA
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Elbow flexion angle during graft fixation for ulnar collateral ligament reconstruction: a systematic review of outcomes and complications. J Shoulder Elbow Surg 2018; 27:2284-2291. [PMID: 30318276 DOI: 10.1016/j.jse.2018.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/14/2018] [Accepted: 07/25/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ulnar collateral ligament (UCL) of the elbow is commonly injured in overhead athletes, especially baseball pitchers. UCL reconstruction has shown good outcomes regarding return to play, but revision rates are on the rise. This review was conducted to determine the effect of elbow flexion angle during graft fixation on outcomes and complications after UCL reconstruction. METHODS MEDLINE, Embase, and PubMed were searched from database inception to November 16, 2017. Patient demographics, surgical technique, graft selection, outcomes, and complications were extracted from the included studies. The quality of each study was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. Descriptive statistics are presented. RESULTS Six studies, with a total of 1168 patients, were included, and all were case series. Excellent Conway scores were present in 83.8% of patients for the 0° to 30° group and in 91.1% of patients for the 45° to 70° group, with no significant differences in return to play between the groups. The rate of revision UCL reconstruction was significantly higher with graft fixation at 0° to 30° (1.4%) compared with fixation at 45° to 70° (0%; P < .01). CONCLUSIONS Elbow flexion angle during graft fixation may not influence return to the same or higher level of competition but appears to influence the need for a revision after UCL reconstruction. However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation.
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Park JY, Seo BH, Hong KH, Lee JH, Oh KS, Chung SW, Noh YM. Prevalence and clinical outcomes of heterotopic ossification after ulnar collateral ligament reconstruction. J Shoulder Elbow Surg 2018; 27:427-434. [PMID: 29433643 DOI: 10.1016/j.jse.2017.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 11/04/2017] [Accepted: 11/14/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction has become increasingly popular in elite athletes. However, the prevalence of heterotopic ossification (HO) formation after UCL reconstruction has not yet been reported. We sought to determine the prevalence of HO formation after UCL reconstruction and the clinical outcomes following HO treatment. MATERIALS AND METHODS From October 2005 to April 2014, 179 patients underwent primary UCL reconstruction. Of the 179 patients, 161 with a minimum of 2 years of follow-up were retrospectively reviewed to evaluate HO formation and clinical outcomes. RESULTS Among 161 patients, HO was detected in 8 cases (5%). Of these 8 patients, 2 were asymptomatic and another 2 complained about transient ulnar neuropathy. The remaining 4 patients had pain; 2 were treated with open excision, and 1 underwent arthroscopic excision. The odds of HO in patients in whom transient ulnar neuropathy develops after UCL reconstruction are 6 times higher than those without transient ulnar neuropathy (odds ratio, 5.957; 95% confidence level, P = .04). Of the 8 patients, 7 returned to the same level or a higher level of competition. HO was found, on average, 5 months (range, 3-9 months) after UCL reconstruction. CONCLUSION The prevalence of HO formation was approximately 5% after UCL reconstruction and increased with transient ulnar neuropathy. After UCL reconstruction, the surgeon should carefully observe HO formation, especially in the early stages after the operation. With appropriate treatment, the clinical outcomes of HO treatment after UCL reconstruction are favorable.
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Affiliation(s)
- Jin-Young Park
- Center for Shoulder, Elbow and Sports Medicine, Neon Orthopaedic Clinic, Seoul, Republic of Korea
| | - Beom Ho Seo
- Center for Shoulder, Elbow and Sports Medicine, Neon Orthopaedic Clinic, Seoul, Republic of Korea.
| | - Kyung-Ho Hong
- Center for Shoulder, Elbow and Sports Medicine, Neon Orthopaedic Clinic, Seoul, Republic of Korea; Department of Orthopedic Surgery, SeoulChuk Hospital, Seoul, Republic of Korea
| | - Jae-Hyung Lee
- Center for Shoulder, Elbow and Sports Medicine, Neon Orthopaedic Clinic, Seoul, Republic of Korea
| | - Kyung-Soo Oh
- Department of Orthopedic Surgery, Konkuk University Hospital, Seoul, Republic of Korea
| | - Seok Won Chung
- Department of Orthopedic Surgery, Konkuk University Hospital, Seoul, Republic of Korea
| | - Young-Min Noh
- Department of Orthopedic Surgery, Dong-A University Hospital, Busan, Republic of Korea
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Molenaars RJ, Hilgersom NFJ, Doornberg JN, van den Bekerom MPJ, Eygendaal D. Review of Jobe et al (1986) on reconstruction of the ulnar collateral ligament in athletes. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Hagemeijer NC, Claessen FMAP, de Haan R, Riedijk R, Eygendaal DE, van den Bekerom MP. Graft Site Morbidity in Elbow Ligament Reconstruction Procedures: A Systematic Review. Am J Sports Med 2017; 45:3382-3387. [PMID: 28314107 DOI: 10.1177/0363546517693836] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Noortje C Hagemeijer
- Orthotrauma Research Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Femke M A P Claessen
- Orthotrauma Research Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
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Abstract
BACKGROUND Chronic ligamentous instability of the elbow is an important pathology as it is accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually a sequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes. DIAGNOSTICS Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A "drop sign" on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy. TREATMENT Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to a return-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with a circumferential graft. 15 cases with promising results have been reported in literature thus far.
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Donohue BF, Lubitz MG, Kremchek TE. Elbow Ulnar Collateral Ligament Reconstruction Using a 4-Strand Docking Plus Technique. Arthrosc Tech 2017; 6:e1201-e1209. [PMID: 29354418 PMCID: PMC5622024 DOI: 10.1016/j.eats.2017.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/25/2017] [Indexed: 02/03/2023] Open
Abstract
The "Docking Plus" technique for elbow ulnar collateral ligament (UCL) surgery is described in the following text and video. Depite the general success of UCL surgery, significant rates of retear and failure of return to competition persist. Hypothesized reasons for UCL surgery failure include insufficient graft strength (midsubstance tears), insufficient graft tensioning (functional UCL insufficiency, valgus extension overload), and insufficient healing of graft to bone (proximal avulsions). This technique is meant to incorporate the best aspects of the previously described techniques for UCL reconstruction to create a larger, stronger, better-tensioned graft with a larger healing surface area to bone, a lower retear rate, and a lower risk of complications. The Docking Plus technique has been used since 2012.
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Affiliation(s)
- Benjamin F. Donohue
- Address correspondence to Benjamin F. Donohue, M.D., M.B.A., Cayuga Medical Associates, 16 Brentwood Drive, Suite A, Ithaca, NY 14850, U.S.A.Cayuga Medical Associates16 Brentwood Drive, Suite AIthacaNY14850U.S.A.
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Milone MT, Starecki M, Ayalon O, Aversano MW, Sapienza A. The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery. J Hand Surg Am 2017; 42:664.e1-664.e5. [PMID: 28606434 DOI: 10.1016/j.jhsa.2017.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 04/24/2017] [Accepted: 05/15/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. METHODS Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. RESULTS Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. CONCLUSIONS Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. CLINICAL RELEVANCE Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.
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Affiliation(s)
- Michael T Milone
- NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, NY.
| | - Mikael Starecki
- NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, NY
| | - Omri Ayalon
- NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, NY
| | | | - Anthony Sapienza
- NYU Langone Orthopaedics, Hospital for Joint Diseases, New York, NY
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Comparison of Surgical Techniques for Ulnar Collateral Ligament Reconstruction in Overhead Athletes. J Am Acad Orthop Surg 2016; 24:135-49. [PMID: 26890035 DOI: 10.5435/jaaos-d-14-00323] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Several surgical techniques and modifications for ulnar collateral ligament (UCL) reconstruction have been proposed since this procedure was first performed in 1974. The goal of these techniques has been restoration of stability to the medial elbow with minimal alteration to the surrounding anatomy. Outcome studies and systematic reviews on modified techniques for UCL reconstruction have shown a trend toward increased return to play in patients, particularly overhead athletes. Abandonment of flexor pronator mass detachment in favor of a muscle-splitting or muscle-elevating approach, minimal handling of the ulnar nerve, and the docking technique may result in improved outcomes and decreased complications without diminished performance. Several biomechanical studies have compared the structural properties of these techniques with those of the native UCL. However, a clear, concise surgical algorithm for UCL reconstruction is lacking. Additional studies that use sport-specific outcome measures and performance metrics may better demonstrate the true return to preinjury performance after UCL reconstruction in overhead athletes.
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Abstract
Ulnar collateral ligament (UCL) injuries are most commonly reported in baseball players (particularly in pitchers) but have also been observed in other overhead athletes including javelin, softball, tennis, volleyball, water polo, and gymnastics. Partial injuries have been successfully treated with appropriate nonoperative measures but complete tears and chronic injuries have shown less benefit from conservative measures. In these cases, surgical reconstruction has become the treatment modality for overhead athlete who wishes to continue to play. This article discusses the functional anatomy and biomechanics of the UCL as related to the pathophysiology of overhead throwing, as well as the important clinical methods needed to make accurate and timely diagnosis. It also gives an updated review of the current clinical outcomes and complications of surgical reconstruction.
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Watson JN, McQueen P, Hutchinson MR. A systematic review of ulnar collateral ligament reconstruction techniques. Am J Sports Med 2014; 42:2510-6. [PMID: 24220014 DOI: 10.1177/0363546513509051] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction of the elbow has become increasingly more frequent among elite overhead athletes. The purpose of this study was to conduct a systematic review comparing the clinical outcomes and biomechanical results of the Jobe, modified Jobe, docking, modified docking, Endobutton, and interference screw techniques for UCL reconstruction. HYPOTHESIS The docking technique will have significantly fewer complications and improved return-to-play rate. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS Using the Medline PubMed, Cochrane, and EMBASE databases, a search was performed of all published articles, including randomized controlled trials, cohort studies, and case series, examining UCL reconstructions performed using one of the above noted techniques and excluding case reports and hybrid techniques. Statistical analysis was performed using a χ(2) test of independence and 2-proportion Z test. RESULTS A total of 21 studies, 7 biomechanical and 14 clinical, met the inclusion criteria. There were 1368 patients. The overall complication rate was 18.6% (255/1368), further subdivided into 21 for the Jobe technique (29.2%), 203 for the modified Jobe technique (19.1%), 2 for the interference screw technique (10.0%), 2 (4.3%) for the modified docking technique, and 10 for the docking technique (6.0%). The most common complication across all studies was ulnar nerve neurapraxia in 176 patients (12.9%). The overall rate of return to play was 78.9%. CONCLUSION Ulnar collateral ligament reconstruction utilizing the docking technique results in a significantly higher rate of return to play and a lower complication rate when compared with the Jobe and modified Jobe techniques. CLINICAL RELEVANCE A lower complication rate can lead to increased rates of return to play and better outcomes postoperatively.
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Affiliation(s)
| | - Peter McQueen
- University of Illinois at Chicago, Chicago, Illinois
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Anakwenze OA, Iyengar JJ, Ahmad CS. Treatment of Medial Collateral Ligament Injuries of the Elbow with Use of the "Tommy John" Operation: Indications and Results. JBJS Rev 2014; 2:01874474-201406000-00003. [PMID: 27500715 DOI: 10.2106/jbjs.rvw.m.00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Oke A Anakwenze
- The San Diego Shoulder and Elbow Service at the Garfield Specialty Center, Kaiser Permanente, 5893 Copley Drive, San Diego, CA 92111
| | - Jaicharan J Iyengar
- Alpine Orthopaedic Medical Group, 2488 North California Street, Stockton, CA 95204
| | - Christopher S Ahmad
- Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, 622 West 168th Street, PH-11, New York, NY 10032
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Elbow ulnar collateral ligament reconstruction: clinical, radiographic, and ultrasound outcomes at a mean 3-year follow-up. Musculoskelet Surg 2014; 98 Suppl 1:87-93. [PMID: 24659202 DOI: 10.1007/s12306-014-0325-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) has the main function to be stress-resistant to elbow valgus overload. Multilayer tears require a reconstruction with a tendon graft. In this study, we report the clinical, radiographic, and ultrasound outcomes after tendon graft reconstruction for symptomatic UCL insufficiency. MATERIALS AND METHODS Among twenty-six subjects underwent elbow UCL reconstruction from 2006 to 2012, fifteen were available to be evaluated at a mean follow-up of 36 months. Preoperative assessment included clinical examination and MRI. The outcome measures were the Mayo Elbow Performance Score (MEPS); the Oxford Elbow Score (OES); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Conway-Jobe Scale. Overall population was postoperatively investigated with X-ray and ultrasound (US). Reconstruction was performed with autograft (palmaris longus) in five cases and allograft (semitendinosus) in ten cases using the figure-of-eight configuration (five cases), the docking technique (eight cases), or a fixation with screws (two cases). RESULTS We found a significant improvement in postoperative MEPS, OES, and DASH scores (p < 0.01). One case was unsatisfied and required an additional procedure of ulnar nerve transposition 12 months after the reconstruction. X-ray showed calcifications along the graft in ten cases. At US examination, all the grafts assessed appeared anatomically intact without structural changes, and the dynamic examination showed a slight medial laxity with the valgus stress maneuver without pain or other sign of medial instability. CONCLUSIONS This study confirms the efficacy of the graft reconstruction for chronic UCL insufficiency and introduces fresh insight on the role of musculoskeletal ultrasound to evaluate the reconstructed UCL.
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Efficacy, usability and tolerability of a dynamic elbow orthosis after collateral ligament reconstruction: a prospective randomized study. Musculoskelet Surg 2013; 98:209-16. [PMID: 24158782 DOI: 10.1007/s12306-013-0301-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 09/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the efficacy, usability and tolerability of a dynamic orthosis compared with a standard plaster splint after the reconstruction of elbow medial or lateral collateral ligaments (MCL, LCL). METHODS Twenty-six subjects undergoing MCL (n = 23) or LCL (n = 3) reconstruction were randomly assigned to immobilization with an orthosis (n = 13; group A "Innovator X") or with a plaster splint (n = 13; group B "Plaster splint"). Outcome measures were visual analogue scale pain score, mid-arm (MA) circumference, grip strength, Oxford elbow score (OES) and range of motion (ROM). Patients were assessed at baseline and at 2, 6, 12 and 24 weeks. RESULTS Significant pain reduction was reported by all patients at 6, 12 and 24 weeks (p < 0.05). Mean MA circumference was significantly higher in group A at all time points (all p < 0.05). Mean grip strength was greater in group A on weeks 2 and 6 (p < 0.05), whereas the difference found on weeks 12 and 24 was not significant. The OES and passive ROM values of the two groups were not significantly different at any time point. CONCLUSIONS The dynamic orthosis and the plaster splint both provided effective and safe elbow immobilization after MCL or LCL reconstruction. The orthosis provided greater pain reduction, faster recovery of muscle trophism and grip strength, and was better tolerated.
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