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Ormiston R, Hargreaves D. 'The treatable triad' long-term functional results of surgically treated acute isolated terrible triad injuries: an 18-year follow-up. J Shoulder Elbow Surg 2024:S1058-2746(24)00555-X. [PMID: 39142433 DOI: 10.1016/j.jse.2024.06.023] [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: 11/23/2023] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Surgical techniques for terrible triad injuries developed 20 years ago. Good and excellent short- and medium-term functional results have been reported. No long-term (over 10 years) functional outcomes have previously been reported. This case-series is the longest follow-up of patients treated for acute isolated terrible triad injuries using a standard treatment protocol. METHODS Twenty patients with acute, isolated, surgically managed terrible triad injuries were treated between October 2001 and May 2008. Ten of these patients were seen face-to face for a clinical follow-up and if required a radiological assessment. Mayo Elbow Performance Scores (MEPSs) and Disabilities of the Arm, Shoulder and Hand (DASH) scores, requirement for further surgery and elbow instability were recorded. RESULTS The average length of follow-up was 18.8 years. The mean Mayo Elbow Performance Score was 88 and the mean Disability of the Arm, Shoulder and Hand score was 12.3. The average loss of pronation was 8°. The average loss of supination was 13°. The reoperation rate was 40%, only one of these was a functionally limiting operation. A trend toward osteoarthritis was observed but there were no conversions to total elbow replacement. DISCUSSION This is the longest-term follow-up study of these injuries and demonstrates the functional performance that the majority of patients achieve. The low follow-up rate can be expected with such a long interval between treatment and assessment. A relatively high reoperation rate is largely made up of minor procedures (removal of metalwork and cubital tunnel release) which did not impact the patients' functional status. This study adds to the evidence that the terrible triad of the elbow is surgically treatable to allow a high functional standard not only in the short-term but also in the long term. As such this is a useful adjunct to have both when informing patients of what can be expected in their long-term recovery from this injury.
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Affiliation(s)
- Rory Ormiston
- Department of Orthopaedics, University Hospital Southampton, Southampton, UK.
| | - David Hargreaves
- Department of Orthopaedics, University Hospital Southampton, Southampton, UK
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2
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Hoshika S, Matsuki K, Takeuchi Y, Takahashi N, Sugaya H. Microscopic Magnetic Resonance Imaging Comparing Asymptomatic and Symptomatic Ulnar Collateral Ligament Injuries in Baseball Players. Am J Sports Med 2024; 52:2314-2318. [PMID: 39101734 DOI: 10.1177/03635465241259472] [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] [Indexed: 08/06/2024]
Abstract
BACKGROUND The relationship between abnormalities of the ulnar collateral ligament (UCL) on magnetic resonance imaging (MRI) and elbow symptoms in baseball players remains unclear. PURPOSE/HYPOTHESIS This study aimed to compare findings of the UCL on microscopic MRI between asymptomatic and symptomatic elbows in baseball players. We hypothesized that the MRI grade of UCL injuries would exhibit no correlation with medial elbow symptoms in baseball players. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS The study participants were skeletally mature baseball players who underwent high-resolution microscopic MRI of the medial elbow including for medical checkups. Elbows with previous surgical treatment or traumatic UCL injuries were excluded. The patients were divided into symptomatic and asymptomatic groups. The UCL appearance on microscopic MRI was categorized into 4 grades and compared between the groups. Abnormal findings in the medial elbow including bony fragments at the medial epicondyle, osteophytes or bony fragments in the sublime tubercle, and bone marrow edema (BME) in the sublime tubercle were also evaluated. RESULTS A total of 426 baseball players (426 elbows) with a mean age of 20 years (range, 14-41 years) were included. The asymptomatic and symptomatic groups included 158 and 268 elbows, respectively. In the asymptomatic group, based on MRI grading of the UCL, 46 (29%) elbows were rated as grade I, 64 (41%) as grade II, 40 (25%) as grade III, and 8 (5%) as grade IV. In the symptomatic group, 75 (28%) elbows were rated as grade I, 118 (44%) as grade II, 61 (23%) as grade III, and 14 (5%) as grade IV. There was no significant difference in the MRI grades between the groups (P = .9). BME in the sublime tubercle was more frequently seen in the symptomatic group than in the asymptomatic group (P < .001). CONCLUSION There was no difference in MRI grades of the UCL between symptomatic and asymptomatic elbows in baseball players; approximately 30% of elbows demonstrated high-grade UCL injuries in both groups. BME in the sublime tubercle was more frequently seen in symptomatic elbows than in asymptomatic elbows. BME in the sublime tubercle was a better indicator of symptoms than was MRI grading of the UCL.
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Affiliation(s)
- Shota Hoshika
- Shoulder & Elbow Service, Funabashi Orthopaedic Sports Medicine & Joint Center, Funabashi, Japan
| | - Keisuke Matsuki
- Shoulder & Elbow Service, Funabashi Orthopaedic Sports Medicine & Joint Center, Funabashi, Japan
| | | | - Norimasa Takahashi
- Shoulder & Elbow Service, Funabashi Orthopaedic Sports Medicine & Joint Center, Funabashi, Japan
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3
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Noda I, Goto R, Yamashita S, Kawanishi K, Tsutsumi M, Kudo S. Assessment of the ulnar nerve stiffness during valgus stress of the elbow using shear wave elastography: an observational cross-sectional study. J Ultrasound 2024:10.1007/s40477-024-00922-8. [PMID: 38900363 DOI: 10.1007/s40477-024-00922-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Identification of the relationship between valgus stress in the medial elbow and ulnar nerve strain during maximum external rotation of the shoulder is pivotal for the prevention and management of ulnar neuropathies. In this observational cross-sectional study, we aimed to determine the changes in ulnar nerve stiffness under valgus stress at different nerve entrapment sites. METHODS Twenty healthy baseball players participated in the study. The stiffness of the ulnar nerve on the throwing side was assessed at two sites, the arcade of Struthers and the Osborne's ligament, at 0°, 60°, and 90° flexion by shear wave elastography using a 10-MHz linear transducer. The arcade of Struthers was defined as the proximal site and the Osborne's ligament as the distal site. Valgus stress was applied to the medial elbow at 0, 30, 50, and 70 N using a Telos stress device, and the stiffness caused by valgus stress was measured. RESULTS At all elbow flexion angles, the stiffness of the ulnar nerve under 70 N valgus stress was higher than that under 30 N stress. The stiffness of the ulnar nerve at the proximal site was significantly higher than that at the distal site. CONCLUSION Valgus stress increases ulnar nerve stiffness. In addition, the stiffness of the proximal site increases.
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Affiliation(s)
- Issei Noda
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, 1-26-16 Nankoukita Suminoe Ward, Osaka, Osaka Prefecture, 559-8611, Japan
- Ashiya Orthopedics Sports Clinic, Hyogo, Japan
- Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Rio Goto
- Yasu Orthopedics Clinic, Hyogo, Japan
| | | | - Kengo Kawanishi
- Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
- Department of Rehabilitation, Kano General Hospital, Osaka, Japan
| | - Masahiro Tsutsumi
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, 1-26-16 Nankoukita Suminoe Ward, Osaka, Osaka Prefecture, 559-8611, Japan
- Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan
| | - Shintarou Kudo
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, 1-26-16 Nankoukita Suminoe Ward, Osaka, Osaka Prefecture, 559-8611, Japan.
- Inclusive Medical Science Research Institute, Morinomiya University of Medical Sciences, Osaka, Japan.
- AR-Ex Medical Research Center, Tokyo, Japan.
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Koseki H, Kajiyama S, Shida T, Tomonaga I, Nishiyama Y, Yoshida D, Mizukami S, Yamaguchi K, Imai C. Characteristics and Clinical Assessment of Elbow Pain in Youth Baseball Players. Sports (Basel) 2024; 12:161. [PMID: 38921855 PMCID: PMC11209444 DOI: 10.3390/sports12060161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
Elbow injuries related to the throwing motion in baseball during the growth period present difficulties for early detection and may cause serious future disabilities. This study aimed to comprehensively determine the characteristics and clinical assessment of elbow pain in youth baseball players. Two hundred and sixteen young baseball players underwent elbow medical examination. Basic information and physical examination, clinical assessment, and ultrasonography results were examined. Univariate analyses were statistically performed between the pain-free (98 participants) and elbow pain (118 participants) groups. The mean age was 11.6 years, and ultrasonographic abnormalities were found on the medial side of the elbow in 37.5%. In total, 118 (54.6%) participants experienced elbow pain, with 64.4% of them complaining of elbow pain on the medial side. Players with multiple positions (≥2 positions) had a significantly higher prevalence of elbow pain. Height, weight, length of baseball experience, and positive rates of horizontal flexion and moving valgus stress tests were higher in the elbow pain group than in the pain-free group. The risk factors and clinical assessment for elbow pain are useful for the prevention and early detection of throwing elbow injuries in youth baseball players.
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Affiliation(s)
- Hironobu Koseki
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan
| | - Shiro Kajiyama
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Takayuki Shida
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Iku Tomonaga
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
| | - Yuta Nishiyama
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan
| | - Daisuke Yoshida
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan
| | - Satoshi Mizukami
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8523, Japan
| | - Kazuhiro Yamaguchi
- Department of Orthopedic Surgery, Yamaguchi Orthopedic Clinic, Nagasaki 850-0013, Japan
| | - Chieko Imai
- Department of Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan
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Funakoshi T, Furushima K, Miyamoto A, Kusano H, Takahashi T, Inoue A, Shimokobe H. Thoracic outlet syndrome in overhead athletes. JSES Int 2024; 8:620-629. [PMID: 38707577 PMCID: PMC11064620 DOI: 10.1016/j.jseint.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background We aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and nonathletes and investigate the return to same-level sports rate in overhead athletes. Methods We retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12-57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 nonathletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand scores, return to same-level sports rate, and ball velocity. Results Overhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and nonathletes (62.8%). The two groups significantly differed in preoperative and postoperative Disability of the Arm, Shoulder, and Hand and recovery rate scores (P = .007, < .001, < .001). Conclusion Overhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with nonathletes and a high return-to-same-level-play rate in sports.
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Affiliation(s)
| | | | | | | | | | - Akira Inoue
- Keiyu Orthopaedic Hospital, Tatebayashi, Japan
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Roubea I, Korakakis V. Rehabilitation following ulnar collateral ligament injury of the elbow in a female acrobatic athlete: A case report. J Bodyw Mov Ther 2024; 38:329-338. [PMID: 38763577 DOI: 10.1016/j.jbmt.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND The mechanism of injury and the conservative rehabilitation of the ulnar collateral ligament of the elbow (UCL) are well studied and reported in overhead athletes, while research on gymnastic athletes is sparse. Evidence suggests exercise as the mainstay in UCL injury rehabilitation. With this report, we aimed to provide a complete rehabilitation protocol following a partial UCL tear of an acrobatic athlete, where exercise and adjunct treatments, such as manual therapy, were used in a progressive staged rehabilitation. CASE DESCRIPTION A 16-year-old female acrobatic athlete was diagnosed with partial tear of the anterior band of UCL. The rehabilitation included progressive exercise loading in conjunction with manual therapy for 10 sessions in 8 weeks. Pain, UCL special tests, the Disabilities of Arm, Shoulder and Hand Score Questionnaire (DASH), and the Upper Limb Functional Index (ULFI) were assessed and administered at baseline and at 3, 6, 10 weeks, and 3 months. RESULTS Improvement in all outcome measures was noted at the 3-month follow-up indicating a substantial reduction in pain and disability, and an increase in stability of the elbow joint. Return to training was achieved at 8 weeks from the initial visit, while return to sport at the pre-injury level was achieved at 3 months. CONCLUSION Progressive exercise loading along with the addition of manual therapy is an effective intervention for the rehabilitation and return to sport following a partial UCL tear. A progressive staged rehabilitation guideline for acrobatic athletes with UCL injuries has been provided to be used and guide clinical practice. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Iliana Roubea
- Physiotherapy Department, University of West Attica, Egaleo, Athens, Greece; Hellenic Orthopaedic Manipulative Therapy Education (HOMT Edu), Athens, Greece.
| | - Vasileios Korakakis
- Hellenic Orthopaedic Manipulative Therapy Education (HOMT Edu), Athens, Greece; Department of Health Sciences, School of Life Sciences and Health Sciences, PhD in Physiotherapy Program, University of Nicosia, Cyprus
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7
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Herring SA, Kibler WB, Putukian M, Boyajian-O'Neill LA, Chang CJ, Franks RR, Hutchinson M, Indelicato PA, O'Connor FG, Powell A, Roach R, Safran M, Statuta SM, Sutton K. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Med Sci Sports Exerc 2024; 56:385-401. [PMID: 37847756 DOI: 10.1249/mss.0000000000003324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
ABSTRACT Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.
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8
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Herring SA, Kibler WB, Putukian M, Boyajian-O'Neill LA, Chang CJ, Franks RR, Hutchinson M, Indelicato PA, O'Connor FG, Powell A, Roach R, Safran M, Statuta SM, Sutton K. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. Curr Sports Med Rep 2024; 23:86-104. [PMID: 38437494 DOI: 10.1249/jsr.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
ABSTRACT Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.
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9
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Savoie FH, O'Brien MJ. Medial elbow injuries in the throwing athlete. J Shoulder Elbow Surg 2024; 33:457-465. [PMID: 37844833 DOI: 10.1016/j.jse.2023.09.012] [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: 05/23/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 10/18/2023]
Abstract
There has been an epidemic increase in injuries to the elbow in our youth sports over the past 15 years. Initially, career-ending elbow injuries occurred almost exclusively in the professional population. The landmark procedure developed by Dr. Frank Jobe, colloquially termed "Tommy John surgery" after the initial player in whom he performed the surgical procedure, allowed roughly two-thirds of professional athletes to return to play at or near the same level. As the surgical procedure became more widespread, modifications of the technique by Jobe and many other contributors raised the return-to-play level to 85%-94% of players regaining the ability to return to sport at the preinjury level. Almost simultaneously, the emphasis on velocity in the professional ranks led to an unintentional increase in stress on the throwing elbow. This was magnified in our athletes by the advent of year-round sports, as well as the formation of "showcase" events to demonstrate skills and measure velocity. This, unfortunately, has resulted in an increase in both repetitive stress injuries and acute traumatic injuries in our young athletes. The purpose of this article is to discuss age-related injuries from both a preventative standpoint and a treatment standpoint.
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Affiliation(s)
- Felix H Savoie
- Department of Orthopaedic Surgery, Tulane University, New Orleans, LA, USA.
| | - Michael J O'Brien
- Shoulder and Elbow Services, Tulane University, New Orleans, LA, USA
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10
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Prabhakar G, Kanawade V, Ghali AN, Dutta AK, Brady CI, Morrey BF. Medial Elbow Pain Syndrome: Current Treatment Strategies. Orthopedics 2023; 46:e81-e88. [PMID: 35876779 DOI: 10.3928/01477447-20220719-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Medial elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. Causes include medial epicondylitis, ulnar neuritis, ulnar collateral ligament injury, flexor pronator strain, or snapping medial triceps. A good outcome is typically achieved with adequate treatment of tendon degeneration at the common flexor tendon origin. Mainstay treatment is nonoperative modalities such as stretching, rest, activity modification, therapy, and injections. If nonoperative management fails, intermediate interventions such as extracorporeal shockwave therapy, platelet-rich plasma injections, prolotherapy, and ultrasound-guided percutaneous tenotomy can be attempted. Surgical treatments are dictated based on the severity of the pathology, involvement of soft tissues, and concomitant pathology. Medial elbow complaints can be multifactorial and require a broad differential diagnosis. [Orthopedics. 2023;46(2):e81-e88.].
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Desai SS, Anderson MJ, Crutchfield CR, Gazgalis A, Alexander FJ, Popkin CA, Ahmad CS. Systematic Assessment of the Quality and Comprehensibility of YouTube Content on Ulnar Collateral Ligament Injury and Management. Orthop J Sports Med 2023; 11:23259671221147921. [PMID: 36970322 PMCID: PMC10034303 DOI: 10.1177/23259671221147921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/26/2022] [Indexed: 03/29/2023] Open
Abstract
Background Ulnar collateral ligament (UCL) reconstruction has received a unique level of attention in the press and social media. There has also been an increasing use of the internet by patients to seek medical information. Concern exists regarding the quality and comprehensibility of online information when used for patient education. Purpose To evaluate the quality and comprehensibility of the most-viewed YouTube videos related to the diagnosis and management of UCL injuries. Based on our new evidence-based scoring rubrics, we hypothesized that the quality and comprehensibility of these videos would be poor. Study Design Cross-sectional study. Methods The YouTube platform was searched on September 7, 2021, with the terms "UCL injury," "ulnar collateral ligament injury," "UCL surgery," "ulnar collateral ligament surgery," and "Tommy John surgery," and the 50 most-viewed videos from each search were compiled, yielding 250 videos. After removal of duplicates and application of exclusion criteria, the 100 most-viewed videos remained. Basic attributes, including duration of video and number of views, were recorded. Each video was then analyzed by 2 independent reviewers and evaluated for 4 key parameters (quality of diagnostic content [QAR-D], quality of treatment content [QAR-T], presence of inaccurate information, and comprehensibility) and graded on a novel scale from 1 to 4 (4 being the most appropriate for patient education). Results The mean QAR-D was 4.83 ± 3.41 (fair quality), and the mean QAR-T was 2.76 ± 3.26 (poor quality). Physician-led educational videos had both the highest mean QAR-D (6.37) and the highest mean QAR-T (4.34). No correlation was observed between video quality and views/likes. A total of 12 videos included ≥1 inaccuracy. The mean comprehensibility score was 2.66 ± 1.12, with 39 videos falling below the acceptable comprehensibility threshold (score <3). Conclusion The overall quality of UCL injury-related YouTube content was low. In addition, the absence of correlation between video quality and views/likes suggests that patients are not preferentially utilizing the limited high-quality content that does exist on the YouTube platform. In addition, inaccurate videos were prevalent (12%), and almost half of all videos were deemed inappropriate for patient education in terms of comprehensibility, as defined by our comprehensibility parameter.
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Affiliation(s)
- Sohil S. Desai
- Columbia University Irving Medical Center, New York, New York,
USA
- Sohil S. Desai, MD, Columbia University Medical Center, 622 W
168th Street, PH 11, New York, NY 10032, USA (
)
| | | | - Connor R. Crutchfield
- Sidney Kimmel Medical College at Thomas Jefferson University,
Philadelphia, Pennsylvania, USA
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12
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Sauder N, Emara AK, Rullán PJ, Molloy RM, Krebs VE, Piuzzi NS. Hip & Knee Are the Most Litigated Orthopaedic Cases: A Nationwide 5-Year Analysis of Medical Malpractice Claims. J Arthroplasty 2022:S0883-5403(22)01027-0. [PMID: 36526101 DOI: 10.1016/j.arth.2022.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Approximately 80% of hip and knee surgeons will face malpractice litigation. Understanding contemporary reasons for litigation and legal outcomes in our field may help surgeons deliver more effective and satisfying care, while limiting their legal exposure. This study aimed to determine: 1) which orthopaedic subspecialties were most frequently litigated; 2) malpractice damages and negligence claimed; 3) the proportion of different case outcomes; and 4) factors associated with defense verdicts. METHODS A nationwide database was queried for all orthopaedic medical malpractice claims (2015 to 2020), obtaining 164 claims from 17 states. Variables included were as follows: case outcome, indemnity payment, damages, negligence claimed, treatment, and patient characteristics. A binary logistic regression determined if any collected variable increased the likelihood of a defense verdict. RESULTS Hip and knee cases were the highest-represented (n = 49, 29.9%; knee: n = 26, 15.9%; hip: n = 23, 14.0%), followed by the spine (n = 36; 22.0%), trauma (n = 29;17.7%), hand and wrist (n = 16; 9.8%), sports (n = 16; 9.1%), foot and ankle (n = 7; 4.3%), pediatric (n = 6; 3.7%), and shoulder (n = 6; 3.7%). Within hip and knee surgery, defense verdicts occurred in 38 cases (77.6%), while 9 (18.4%) resulted in plaintiff verdicts (mean payment: $4,866,929) and 2 (4.1%) resulted in settlements (mean settlement: $1,550,000). Nonreversible damages (eg, paralysis, amputation, and death; P < .001) were associated with a decreased likelihood of a defense outcome. CONCLUSION Hip and knee cases were the highest-represented in orthopaedic malpractice litigation. Surgeons were more frequently found negligent when nonreversible damages occurred. Orthopaedic surgeons should be cognizant of litigation patterns while ensuring patient-centered high-quality care.
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Affiliation(s)
- Nicholas Sauder
- School of Medicine, Case Western Reserve University, Cleveland, Ohio; Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pedro J Rullán
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Viktor E Krebs
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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13
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Liu W, Xiong H, Wang W, Chen S, Li F, Liu J, Yan H, Zhang J, Qian Y, Fan C. Effectiveness and safety of a less-invasive MCL reconstruction technique for contracted or ossified ligaments in patients with elbow stiffness: An open-label, non-randomised, prospective, multicentre trial in China. EClinicalMedicine 2022; 52:101616. [PMID: 36016695 PMCID: PMC9396044 DOI: 10.1016/j.eclinm.2022.101616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The elbow joint is sensitive to trauma from accidents, sports injuries, and surgical trauma. Some patients develop ossification or contracture of the medial collateral ligament (MCL) after elbow trauma. A less invasive reconstruction of the MCL can be performed after resection of diseased MCL. The biomechanical characteristics of this technique have been demonstrated and validated. However, its clinical effectiveness and safety require further confirmation in clinical practice. METHODS This open-label, non-randomised, prospective, multicentre trial included consecutive patients with elbow stiffness from five orthopaedic centres in China. Patients willing to participate in the study, with elbow stiffness caused by traumatic injury, who had reached skeletal maturity, and who had a range of motion of <100° were eligible for inclusion. Patients with immunological or metabolic causes of elbow stiffness, burns, or central nervous system injuries were excluded. In addition, patients who did not require MCL release and reconstruction after intraoperative release of other structures were also excluded. All patients underwent resection of the diseased MCL part in an open arthrolysis. Medial stability of the elbow was reconstructed using a less invasive MCL reconstruction technique that uses fascia and tendon patches. In this study, the primary outcomes, including stability, Mayo Elbow Performance Score (MEPS), Amadio score, were used to comprehensively evaluate this technique. Outcomes were assessed at 6 weeks, 6 months, and 1 year postoperatively and annually thereafter. This study reports the results of one arm of the trial that has been registered with the Chinese Clinical Trial Registry (chictr.org.cn), ChiCTR-INC-16010019. FINDINGS Between January 1, 2017 and March 1, 2020, 104 eligible patients were enrolled. The mean follow-up time was 43·47 (95% CI, 41·45 - 45·49) months. Among all 104 patients, 100 (96%) patients who underwent MCL reconstruction retained medial stability at the last follow-up. All outcomes from the last follow-up were used for comparison with the preoperative outcomes. No differences in preoperative and postoperative stability scores were observed (P = 0·7820). Extension, flexion, pronation, and supination of the injured elbow improved significantly (P < 0·0001, P < 0·0001, P < 0·0001, P < 0·0001). The mean range of motion (ROM) and forearm rotational range of motion (FRR) increased by 71·25° (152%) (P < 0·0001) and 30·83° (25%) (P < 0·0001), respectively. Additionally, the Mayo Elbow Performance Score (MEPS) and muscle strength had increased after evaluation at follow-ups (P < 0·0001, P < 0·0001). Drastic pain relief and nerve symptom reduction were observed, as evaluated using VAS scores and Amadio scores, respectively (P < 0·0001, P < 0·0001). Seventeen (16%) patients experienced a recurrence of elbow stiffness of varying severity, but only two patients had poor or fair results. Several common and non-severe complications, including infection in one (1%) patient, new nerve symptoms in seven (7%) patients, new pain in one (1%) patient, fracture in one (1%) patient, and valgus instability in four (4%) patients, were observed and properly treated in this study. INTERPRETATION The less invasive MCL reconstruction technique using fascia and tendon patches is an effective method for restoring medial stability in patients with elbow stiffness after complete arthrolysis with certain safety. The technique shows prospects for elbow MCL reconstruction in clinical practice. FUNDING The study was supported by the National Key Research and Development Program of China (No. 2021YFC2400805), National Natural Science Foundation of China (No. 81830076), Young Elite Scientist Sponsorship Program by Cast (No. YESS20200153), Shanghai Sailing Program (No. 20YF1436000), Shanghai Municipal Science and Technology Commission Foundation (No.19ZR1439200), Municipal Hospital Newly-developing Cutting-edge Technologies Joint Research Program of Shanghai Shenkang Hospital Development Centre (No. SHDC12018130).
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Affiliation(s)
- Wenjun Liu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital, Shanghai, PR China
| | - Hao Xiong
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Fengfeng Li
- Department of Orthopaedics, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Junjian Liu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Hede Yan
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Jingwei Zhang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital, Shanghai, PR China
- Corresponding authors.
| | - Yun Qian
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
- Corresponding authors.
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
- Corresponding authors.
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14
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Bowers RL, Lourie GM, Griffith TB. Diagnosis and Treatment of Posteromedial Elbow Impingement in the Throwing Athlete. Curr Rev Musculoskelet Med 2022; 15:513-520. [PMID: 36006592 PMCID: PMC9789259 DOI: 10.1007/s12178-022-09789-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Posteromedial elbow impingement is a common pathological entity in the throwing athlete. The posteromedial articulation of the elbow is a significant stabilizer to medial elbow forces and valgus stress noted during repetitive throwing. This current review investigates recent literature regarding the relevant anatomy, diagnosis, and treatment of posteromedial impingement in the thrower. RECENT FINDINGS Improvements in advanced imaging have provided accurate and detailed diagnostic capability for the assessment of the throwers' elbow. After failure of conservative measures, arthroscopic treatment of posteromedial elbow impingement with posteromedial osteophyte removal has demonstrated excellent outcomes with a reliable return to play in the competitive thrower. In addition to a thorough history and physical examination, MRI, MR arthrogram, CT, and dynamic ultrasound imaging modalities are useful in the assessment of a presumed diagnosis of posteromedial impingement. Arthroscopic decompression with posteromedial osteophyte removal provides effective clinical results and return to play. The surgeon should be careful to avoid creating medial ulnar collateral instability by means of over-resection of the posteromedial olecranon.
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Affiliation(s)
- R. L. Bowers
- Atlanta Braves Baseball Club, Emory Sports Medicine Center, Emory University School of Medicine, 21 Ortho Lane, Atlanta, GA 30329 USA
| | - G. M. Lourie
- Atlanta Braves Baseball Club, The Hand and Upper Extremity Center of Georgia, Atlanta, GA USA
| | - T. B. Griffith
- Atlanta Braves Baseball Club, Peachtree Orthopaedics, Atlanta, GA USA
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15
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Vaswani R, White A, Dines J. Medial Ulnar Collateral Ligament Injuries in Contact Athletes. Curr Rev Musculoskelet Med 2022; 15:474-482. [PMID: 35917095 PMCID: PMC9789220 DOI: 10.1007/s12178-022-09785-0] [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] [Accepted: 07/09/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review medial ulnar collateral ligament (UCL) injuries in contact athletes. UCL injuries in overhead throwing athletes are typically chronic attenuation due to repetitive valgus stress on the elbow during the throwing motion. As such, UCL reconstruction is commonly performed for these athletes. In contrast, UCL injuries in contact athletes are usually acute ligament tears or avulsions of a ligament with otherwise normal tissue. Nonoperative treatment is typically the first-line treatment for partial injuries. UCL repair may work well for acute complete injuries and may avoid the donor site morbidity of UCL reconstruction. RECENT FINDINGS Most of the literature regarding UCL injuries have been performed in baseball players. Historically, UCL repair has had poor outcomes in baseball players due to the chronic ligament attenuation. Therefore, much of the recent literature has focused on outcomes of UCL reconstruction, which are generally excellent. However, there is a paucity of literature studying outcomes of UCL injuries in contact athletes and those studying UCL repair. One recent study looked at a new technique for UCL repair with collagen-coated fiber tape augmentation in baseball players and found good short-term outcomes. UCL injuries in contact athletes occur typically as acute tears or avulsions. While UCL reconstruction has typically been recommended as the accepted treatment for UCL tears that require operative treatment, UCL repair may be a good alternative in contact athletes.
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Affiliation(s)
- Ravi Vaswani
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.
| | - Alex White
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Joshua Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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16
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Thigpen CA, Kissenberth MJ. Professional Pitchers Display Differences in UCL Morphology and Elbow Gapping During Moving Valgus Stress Testing After UCLR: Response. Orthop J Sports Med 2022; 10:23259671221103595. [PMID: 35770139 PMCID: PMC9234845 DOI: 10.1177/23259671221103595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Ben Abdellah A, Ben Salah S, Darraz S, Tebbaa A, Jelti O, Mokhtari O, Moulay Rchid I, Rachdi Y, Lachkar A, Najib A, Yacoubi H. Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco. Ann Med Surg (Lond) 2022; 78:103914. [PMID: 35734695 PMCID: PMC9207080 DOI: 10.1016/j.amsu.2022.103914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction The terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco. Patients and methods This was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination. Results 6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case. Conclusion The surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament. The terrible triad of the elbow is a complex injury affecting both the bone and ligaments. A complete and accurate management of this entity during any trauma of the elbow is required. A careful clinical and radiological assessments must be performed during complex elbow trauma. The main objective of any treatment is to provide a stable elbow and avoid early arthrosis.
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Affiliation(s)
- A. Ben Abdellah
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
- Corresponding author. Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco.
| | - S. Ben Salah
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - S. Darraz
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - A. Tebbaa
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - O. Jelti
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - O. Mokhtari
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - I. Moulay Rchid
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - Y. Rachdi
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - A. Lachkar
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - A. Najib
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
| | - H. Yacoubi
- Department of Traumatology and Orthopedics, Mohammed VI University Hospital, Oujda, Morocco
- Faculty of Medicine and Pharmacy, Mohammed 1 University, Oujda, Morocco
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18
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Uno T, Honma R, Takahara M, Satake H, Oishi R, Maruyama M, Takagi M. Combining Cylindrical Bone Graft and Headless Screw Fixation for Nonunion of the Medial Trochlea of the Elbow: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00036. [PMID: 36099502 DOI: 10.2106/jbjs.cc.22.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE A 19-year-old handballer presented with elbow pain and nonunion of the medial trochlea of the elbow. He had undergone earlier surgery for an elbow injury at 6 years of age. Revision surgery for nonunion was performed using an extra-articular method combining cylindrical bone graft and headless screw fixation. Partial union was observed, and he resumed sports after 3 months, with his limb largely pain-free and functional. At the 21-month follow-up, bone healing was complete. CONCLUSIONS Combining cylindrical bone graft and headless screw fixation using the extra-articular technique is an option for managing nonunion of the medial trochlea of the elbow.
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Affiliation(s)
- Tomohiro Uno
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
- Department of Orthopaedic Surgery, Yoshioka Hospital, Tendo, Yamagata, Japan
| | - Ryusuke Honma
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Masatoshi Takahara
- Department of Orthopaedic Surgery, Izumi Orthopaedic Hospital, Sendai, Miyagi, Japan
| | - Hiroshi Satake
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Ryuta Oishi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Masahiro Maruyama
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
| | - Michiaki Takagi
- Department of Orthopaedic Surgery, Yamagata University Faculty of Medicine, Yamagata, Yamagata, Japan
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19
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Otoshi K, Kikuchi S, Kato K, Kaneko Y, Mashiko R, Sato R, Igari T, Kaga T, Konno S. The Influence of Chronic Medial Epicondylar Apophysitis on Medial Ulnar Collateral Ligament Insufficiency - Retrospective Cohort Study. JSES Int 2022; 6:539-544. [PMID: 35572434 PMCID: PMC9091731 DOI: 10.1016/j.jseint.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background This study aimed to investigate the effect of chronic traction apophysitis of the medial epicondyle (MEC) on medial ulnar collateral ligament (MUCL) insufficiency in high school baseball players. Methods In this retrospective cohort study, 3034 of 6069 high school baseball players were enrolled. A self-reported questionnaire was distributed to investigate past history of elbow pain and elbow pain during the previous season. Physical examinations to assess tenderness on the MUCL and the elbow valgus stress test (EVST) were performed. Ultrasonography was performed to determine the presence of morphological abnormalities of the anteroinferior aspect of the MEC (MEC lesions). Results Participants with MEC lesions had a significantly higher prevalence of past history of elbow pain, elbow pain during the previous season, MUCL tenderness, and positive EVST than those without MEC lesions (P < .05). Multivariate logistic regression analysis revealed that the participants with the fragmented type had the highest risk of past history of elbow pain (odds ratio [OR] = 3.94), elbow pain during the previous season (OR = 2.27), positive EVST (OR = 3.49), and the second highest risk of MUCL tenderness (OR = 2.01) followed by the irregular type (OR = 2.31). Participants with the hypertrophic type had the lowest risk of past history of elbow pain (OR = 2.08), elbow pain during the previous season (OR = 1.42), MUCL tenderness (OR = 1.09), and positive EVST (OR = 1.47). Conclusion The presence of chronic non-healed traction apophysitis of the MEC in high school baseball players presented a significantly high risk of elbow pain and MUCL insufficiency.
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20
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Kissenberth MJ, Thigpen CA, Bailey LB, Campbell J, Geist DJ, Schweppe ML, Wyland DJ, Hawkins RJ, Noonan TJ, Shanley E. Professional Pitchers Display Differences in UCL Morphology and Elbow Gapping During Moving Valgus Stress Testing After UCL Reconstruction. Orthop J Sports Med 2021; 9:23259671211035734. [PMID: 34746324 PMCID: PMC8564131 DOI: 10.1177/23259671211035734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/25/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) of the elbow has
received much attention given the rise in incidence among baseball pitchers.
Stress ultrasonography has been demonstrated to be a critical evaluation
tool of the UCL. No study has dynamically evaluated the ability of UCLR to
restore normal kinematics. Purpose/Hypothesis: The purpose of this study was to compare ulnohumeral gapping during a moving
valgus stress test as well as UCL thickness between professional pitchers
with and without UCLR. We hypothesized that the ulnohumeral joint will
display greater gapping and the UCL graft will be thicker in pitchers after
UCLR compared with uninjured pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Ultrasonography was used to measure the medial ulnohumeral joint distance and
the UCL thickness of 70 asymptomatic professional baseball pitchers; 6 of
the participants had a history of UCLR. Images were captured of the dominant
(D) and nondominant (ND) elbows at the maximal cocking position under 2
loaded conditions within the moving valgus stress test arc: (1) gravity
stress and (2) 2.5 kg (5.5 lb) of valgus force using a dynamometer. Intra-
and interrater reliability of the measurements was established with
intraclass correlation coefficients (ICCs). Separate mixed-model analyses of
variance (D side × UCL) were used to compare the D and ND elbow variables
between pitchers with and without a history of UCLR. Results: All measurements displayed good reliability according to ICCs. Pitchers with
a history of UCLR demonstrated less gapping (5.6 ± 2.9 vs 4.2 ± 1.2 mm;
P = .002) and greater UCL graft thickness (0.17 ± 0.07
vs 0.11 ± 0.08 mm; P = .03) compared with the native
ligament in pitchers without prior UCL injury. Conclusion: Our data demonstrated that the UCLR results in a thicker, stiffer construct
with less medial elbow gapping than the anatomical UCL. Using ultrasound to
evaluate the UCL was a reliable, efficient, and clinically feasible method
to assess UCL thickness and joint gapping in players with a history of UCLR.
Future studies may consider this approach to evaluate surgical techniques
and graft types for UCLR.
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Affiliation(s)
- Michael J Kissenberth
- Prisma Health Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, USA.,Hawkins Foundation, Greenville, South Carolina, USA
| | - Charles A Thigpen
- Hawkins Foundation, Greenville, South Carolina, USA.,ATI Physical Therapy, Greenville, South Carolina, USA
| | | | - Joel Campbell
- Prisma Health Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, USA
| | - Derik J Geist
- West Virginia University Medicine, Morgantown, West Virginia, USA
| | | | - Douglas J Wyland
- Prisma Health Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, USA.,Hawkins Foundation, Greenville, South Carolina, USA
| | | | - Thomas J Noonan
- Steadman Hawkins Clinic Denver, Greenwood Village, Colorado, USA
| | - Ellen Shanley
- Hawkins Foundation, Greenville, South Carolina, USA.,ATI Physical Therapy, Greenville, South Carolina, USA
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21
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Abstract
Utilization of musculoskeletal ultrasound, in particular for sports medicine, has dramatically increased in recent years. Ultrasound is an important adjunct tool to physical examination and other imaging methods in the evaluation and management of the injured athlete. It offers unique advantages in specific clinical scenarios. Dedicated training and a standardized scanning technique are important to overcome the inherent operator dependence and avoid diagnostic pitfalls. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies. This article reviews the general ultrasound appearance of muscle, tendon, ligament, and nerve abnormalities in the athlete with a focus on sport-specific injuries.
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22
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Sportartenspezifische Probleme des Ellenbogens. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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FEVER: The Flexed Elbow Valgus External Rotation View for MRI Evaluation of the Ulnar Collateral Ligament in Throwing Athletes-A Pilot Study in Major League Baseball Pitchers. AJR Am J Roentgenol 2021; 217:1176-1183. [PMID: 34076462 DOI: 10.2214/ajr.21.25608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Ulnar collateral ligament (UCL) injuries are common in throwing athletes due to repetitive extreme valgus stress during overhead throwing maneuvers. Conventional positioning for elbow MRI provides suboptimal rendering of the UCL. Objective: To perform a prospective pilot study assessing the impact of a flexed elbow valgus external rotation (FEVER) view on ulnotrochlear (UT) joint space measurement and reader evaluation of the UCL when incorporated into standard elbow MRI in throwing athletes. Methods: A total of 44 Major League Baseball pitchers underwent elbow MRI including standard sequences and a coronal fat-saturated proton density-weighted sequence in the FEVER view that uses specific positioning maneuvers and sandbags to immobilize the elbow in valgus stress and visualize the UCL parallel to its long axis. Patients recorded pain during FEVER view [0 (none) to 10 (maximal)]. Two radiologists independently evaluated standard and FEVER views to measure the UT joint space, assess confidence in UCL-related findings, and assess the UCL as normal or abnormal. Results: Pain during FEVER view was: 0 (n=29), 1-3 (n=11), 4-7 (n=4), 8-10 (n=0). Intrareader agreement for UT joint space measurement was higher for FEVER [intraclass correlation coefficient (ICC)=0.92] than standard (ICC=0.54) views. Averaged between readers, mean UT joint space increase on FEVER compared with standard view was 1.80 mm (95% CI: 1.58, 2.03). Confidence was higher for FEVER than standard view for reader 1 for assessment of the UCL as normal versus abnormal (mean increase in confidence of 0.41), intensity of abnormal signal (0.44), injury grade (0.98), and retraction (0.20), and for reader 2, assessment of the UCL as normal versus abnormal (0.50), location of abnormal signal (0.42); intensity of abnormal signal (0.47), injury grade (0.89), and retraction (0.50). Readers 1 and 2 classified 3 and 2 additional UCLs as abnormal on FEVER compared with standard view; neither reader classified any UCL as abnormal in standard view but normal in FEVER view. Conclusion: The increased joint space width confirms elbow valgus stress with FEVER view. Diagnostic confidence increased, and additional UCLs were identified as abnormal. Clinical Impact: The FEVER view may improve MRI evaluation of the UCL in throwing athletes.
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24
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Hämäläinen T, Ahonen M, Helenius I, Jalkanen J, Lastikka M, Nietosvaara Y, Salonen A, Sinikumpu JJ, Grahn P. Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial. BMJ Open 2021; 11:e044627. [PMID: 33941629 PMCID: PMC8098981 DOI: 10.1136/bmjopen-2020-044627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with >2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment. METHODS AND ANALYSIS This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score. ETHICS AND DISSEMINATION Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals. TRIAL REGISTRATION The trial has been registered at clinicaltrials.gov with registration number NCT04531085.
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Affiliation(s)
- Tero Hämäläinen
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Matti Ahonen
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Ilkka Helenius
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Jenni Jalkanen
- Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Markus Lastikka
- Department of Paediatric Orthopaedic Surgery, TYKS Turku University Hospital, Turku, Varsinais-Suomi, Finland
| | - Yrjänä Nietosvaara
- Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Pohjois-Savo, Finland
| | - Anne Salonen
- Department of Pediatric Surgery, Tampere University Hospital, Tampere, Finland
| | | | - Petra Grahn
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
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25
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Looney AM, Rigor PD, Bodendorfer BM. Evaluation and management of elbow injuries in the adolescent overhead athlete. SAGE Open Med 2021; 9:20503121211003362. [PMID: 33996078 PMCID: PMC8072106 DOI: 10.1177/20503121211003362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 11/22/2022] Open
Abstract
With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.
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Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
| | - Paolo D Rigor
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Blake M Bodendorfer
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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26
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Lateral ulnar collateral ligament (LUCL) reconstruction for the treatment of recalcitrant lateral epicondylitis of the elbow: a comparison with open débridement of the extensor origin. JSES Int 2021; 5:578-587. [PMID: 34136874 PMCID: PMC8178594 DOI: 10.1016/j.jseint.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Based on the controversy over whether the extensor tendon is the only lesion of lateral epicondylitis of the elbow and numerous reports of concomitant lateral collateral ligament involvement, potential damage to the lateral collateral ligament complex should be considered for the treatment. Methods About 25 elbows in 23 patients (débridement group) and 22 elbows in 20 patients (reconstruction group) who were diagnosed with lateral epicondylitis and had an average of 22 months of symptoms revealing anatomical lesion on MRI were included. The capitellum-sublime tubercle-radial head (CSR) angle was measured on both sides preoperatively, and the visual analog scale (VAS) and Mayo elbow performance score (MEPS) were measured over 12 months, postoperatively. Results The initial preoperative mean VAS was statistically significant with 4.6 in the débridement group and 6.5 in the reconstruction group (P < .05). Postoperative VAS was continuously decreased in both groups with no significant difference at each assessment period (P < .05) but showed more rapid improvement in the reconstruction group compared with the débridement group. For MEPS, the reconstruction group showed significant improvement during the follow-up periods, and at the final follow-up MEPS, 3 cases in the débridement group and 0 cases in the reconstruction group showed a poor result, which was considered as surgery failure. The CSR angle of the affected side (7.2 ± 1.9) was significantly larger than that of the normal side (3.6 ± 1.5) (P < .05) in the reconstruction group. Increased CSR by more than 5 degrees was identified as a significant predictive indicator for potential concomitant ligament insufficiency (area under curve = 0.875, P < .001) showing 80.9% of the sensitivity, 82.1% of the specificity. Conclusions In the surgical treatment of recalcitrant lateral epicondylitis, lateral ulnar collateral ligament reconstruction added to the débridement of extensor origin may provide better results for the patients with suspicious lateral ligament insufficiency or failed previous surgery.
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27
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Grahn P, Hämäläinen T, Nietosvaara Y, Ahonen M. Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Acta Orthop 2021; 92:114-119. [PMID: 33073625 PMCID: PMC7919892 DOI: 10.1080/17453674.2020.1832312] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population.Patients and methods - 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1-6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds.Results - Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7-15 years was ≥ 3:100,000.Interpretation - Displaced fractures of the medial humeral epicondyle in children heal well with 3-4 weeks' immobilization. Open reduction and screw fixation does not improve outcome.
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Affiliation(s)
- Petra Grahn
- Department of Pediatric Orthopedics and Traumatology, New Children’s Hospital, HUS Helsinki University Hospital, Helsinki
| | - Tero Hämäläinen
- Department of Orthopedics and Traumatology, HUS Helsinki University Hospital, Helsinki
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, New Children’s Hospital, HUS Helsinki University Hospital, Helsinki
- Department of Pediatric surgery, Kuopio University Hospital, Kuopio, Finland
| | - Matti Ahonen
- Department of Pediatric Orthopedics and Traumatology, New Children’s Hospital, HUS Helsinki University Hospital, Helsinki
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28
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Lawton CD, Swensen-Buza S, Awender JF, Pinnamaneni S, Lamplot JD, Young WK, Rodeo SA, Nawabi DH, Taylor SA, Dines JS. The Elbow Physical Examination for Telemedicine Encounters. HSS J 2021; 17:65-69. [PMID: 33967644 PMCID: PMC8077976 DOI: 10.1177/1556331620975040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/28/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Cort D. Lawton
- Sports Medicine Division, Ortho Illinois, Algonquin, IL, USA
| | | | | | | | - Joseph D. Lamplot
- Department of Orthopedics, Sports Medicine Division, Emory University, Atlanta, GA, USA
| | - Warren K. Young
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Scott A. Rodeo
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Danyal H. Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Samuel A. Taylor
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Joshua S. Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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29
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THE NONOPERATIVE REHABILITATION OF A TRAUMATIC COMPLETE ULNAR COLLATERAL LIGAMENT TEAR OF THE ELBOW IN A HIGH SCHOOL WRESTLER: A CASE REPORT. Int J Sports Phys Ther 2020; 15:1211-1221. [PMID: 33344036 DOI: 10.26603/ijspt20201211] [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] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Injuries frequently occur in competitive wrestling, with the elbow joint representing about 25% of all injuries. Specific to the elbow, the ulnar collateral ligament (UCL) can be injured traumatically from takedowns in wrestling. In athletes with complete UCL tears, surgical management is often recommended with nonoperative management resulting in less favorable outcomes. The purpose of this case report is to present a nonoperative criterion-based rehabilitation program for a high school wrestler with a complete UCL tear of the elbow. Case Description A 17-year-old male wrestler presented to outpatient physical therapy with a complete UCL tear sustained from falling on an outstretched hand during a wrestling match. He presented with limited elbow range of motion (ROM), medial elbow instability, and weakness of the involved shoulder and forearm musculature. A three staged criterion-based rehabilitation protocol was developed for this subject based on specific criteria, including pain, elbow ROM, arm strength, and functional outcomes. Outcomes The subject was treated for nine visits over six weeks, and demonstrated improvements in all strength tests of the involved upper extremity, with elbow flexion strength improving the most by 58%. Return to sport (RTS) tests were used to assess the subject's ability to return to practice. At approximately eight weeks after initial injury, the subject was able to return to full participation in competitive wrestling with no reports of elbow pain or instability. Discussion Through the utilization of a criterion-based rehabilitation protocol for the nonoperative management of an UCL injury, this high school wrestler was able to safely progress back to wrestling without pain or instability in an accelerated time frame. Previously, no detailed rehabilitation guidelines for nonoperative management of UCL injuries in contact sports have been described. Additionally, few studies exist which report on the inclusion of RTS testing following an injury to the UCL of the elbow, as RTS testing is optimal for determining readiness for sport. Level of Evidence 4, Case Report.
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30
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Seiber K, Bales C, Wörner E, Lee T, Safran MR. Assessment of the reliability of a non-invasive elbow valgus laxity measurement device. J Exp Orthop 2020; 7:74. [PMID: 32989568 PMCID: PMC7522144 DOI: 10.1186/s40634-020-00290-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
Purpose The purpose of this study was to assess the reliability of a new objective measurement tool to measure the valgus stress laxity of the ulnar collateral ligament (UCL) of the elbow, the “Elbow Tester”. The anterior oblique portion of the ulnar collateral ligament (UCL) of the elbow is the primary static restraint to valgus stress during the overhead throwing motion. The main research question was if the “Elbow Tester” that we have developed was reliable and reproducible for further use in research and daily practice. Methods Three different examiners tested both elbows of 11 volunteers for UCL laxity. Each elbow was tested 5 times using a standard 2 Nm valgus load, and 3 times using a manual maximum valgus load. One examiner tested the volunteers again 1 week later. The outcomes of elbow valgus laxity were compared between examiners. The intraobserver reliability was assessed using an intraclass correlation coefficient (ICC) and interobserver reliability was also assessed with a mixed model repeated ANOVA test. Results The device demonstrated a high level of intraobserver reliability with both the 2 Nm valgus force and manual maximum valgus force, using a minimum of three trials as determined by an ICC > 0.9 for all examiners. The interobserver reliability was moderate using the 2 Nm valgus load with an ICC value of 0.72 and significant different outcomes of elbow valgus laxity amongst examiners (p < 0.01). A high interobserver reliability (ICC value of 0.90) was observed using manual maximum valgus force and no differences between outcomes (p > 0.53). Conclusion The noninvasive valgus elbow tester demonstrates high interobserver and intraobserver reliability using manual maximum valgus force and can be used for further research and daily practice.
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Affiliation(s)
- Kenneth Seiber
- Department of Orthopaedic Surgery, Stanford University, 430 Broadway, MC 6342, Redwood City, CA, 94063, USA
| | - Chris Bales
- Department of Orthopaedic Surgery, Stanford University, 430 Broadway, MC 6342, Redwood City, CA, 94063, USA
| | - Elisabeth Wörner
- Department of Orthopaedic Surgery, Stanford University, 430 Broadway, MC 6342, Redwood City, CA, 94063, USA.
| | - Thay Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Stanford University, 430 Broadway, MC 6342, Redwood City, CA, 94063, USA
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31
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Harada M, Takahara M, Maruyama M, Sasaki J, Satake H, Uno T, Mura N, Takagi M. Comparison of Radiographic and Ultrasonographic Findings of Medial Elbow Laxity in High School Baseball Players. Open Orthop J 2020. [DOI: 10.2174/1874325002014010073] [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] [Indexed: 02/22/2023] Open
Abstract
Background:
Although ultrasonography has been used to assess medial elbow laxity, its usefulness has not yet been confirmed.
objective:
The aim of this study were to assess medial elbow laxity in high school baseball players based on measurements of the medial joint space (MJS) of the elbow using ultrasonography and radiography and to investigate the correlation between these assessments.
Methods:
Thirty-two high school baseball players participated in this study. Fourteen players (44%) were diagnosed with Ulnar Collateral Ligament (UCL) injury. Valgus stress was applied to the elbow by gravity during ultrasonographic and radiographic assessments, and the MJS was measured. The MJS of the throwing side was compared with that of the non-throwing side, and the increase in the MJS of the throwing side was determined. The correlation between ultrasonographic and radiographic assessments was investigated and the usefulness of these assessments for the diagnosis of UCL injury was evaluated.
Results:
A moderate correlation was found between the ultrasonographic and radiographic assessments of the MJS of the throwing side (correlation coefficient=0.547, P=0.0009). Furthermore, a weak correlation was found for the increase in MJS (correlation coefficient=0.348, P=0.0505), although it was not significant. The comparisons of the radiographic assessments between the UCL injury and non-UCL injury groups showed a significant difference in both the MJS of the throwing side (P=0.0068) and the increase in the MJS (P=0.02), although no difference was found using ultrasonography.
Conclusion:
Ultrasonography, similar to radiography, is useful for assessing medial elbow laxity. While radiography is useful for diagnosing UCL injury.
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32
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Ciccotti MC, Ciccotti MG. Ulnar Collateral Ligament Evaluation and Diagnostics. Clin Sports Med 2020; 39:503-522. [DOI: 10.1016/j.csm.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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33
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Anderson FL, Heffernan JT, Ahmad CS. UCL Reconstruction in the Throwing Elbow. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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34
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Ciccotti MC, Ciccotti MG. Exam and Imaging of the Throwing Elbow. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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35
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Abstract
Ulnar collateral ligament (UCL) injuries can significantly impair the overhead athlete. Reconstruction of the anterior bundle of the UCL (UCL-R) has allowed a high proportion of these individuals to return to their previous level of play. Several techniques for UCL-R are described that produce acceptable results with an overall low complication rate. Transient ulnar neuritis is the most common complication following UCL-R. The rate of UCL injury in young athletes is rising with increased youth involvement and year-round participation in overhead sports. The sports medicine community must broaden its focus to not only treat UCL injuries but also prevent them.
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Affiliation(s)
- Edward Lyle Cain
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA.
| | - Mims G Ochsner
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA
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36
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Alrabaa RG, Dantzker N, Ahmad CS. Injuries and Conditions Affecting the Elbow Flexor/Pronator Tendons. Clin Sports Med 2020; 39:549-563. [PMID: 32446574 DOI: 10.1016/j.csm.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Common flexor-pronator tendon injuries and medial epicondylitis can be successfully treated nonoperatively in most cases. Operative treatment is reserved for patients with continued symptoms despite adequate nonoperative treatment or in high-level athletes with complete rupture of the common flexor-pronator tendon. The physical examination and workup of patients with flexor-pronator tendon injuries should focus on related or concomitant pathologies of the medial elbow. The gold standard for surgical treatment of flexor-pronator tendon ruptures or medial epicondylitis includes tendon debridement and reattachment.
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Affiliation(s)
- Rami George Alrabaa
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA.
| | - Nicholas Dantzker
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY 10032, USA
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37
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Savoie FH, O'Brien M. Sprains, Strains, and Partial Tears of the Medial Ulnar Collateral Ligament of the Elbow. Clin Sports Med 2020; 39:565-574. [PMID: 32446575 DOI: 10.1016/j.csm.2020.02.007] [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] [Indexed: 10/24/2022]
Abstract
Medial ulnar collateral ligament (MUCL) insufficiency is becoming common in younger, nonprofessional athletes. In contrast to elite athletes who develop valgus extension overload syndrome and associated chronic pathologic changes in the MUCL, younger patients present with sprains and partial tears that can often be managed non-operatively with successful outcome and rapid return to play. In the younger throwing athlete with medial-sided elbow pain, a hinged elbow brace and rehabilitation of dysfunctional muscles often lead to successful recovery and return to play within 1-2 months. In more severe injuries, direct repair of the partial tear with or without added internal bracing supplementation allows restoration of stability with a return to play with 4 to 6 months.
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Affiliation(s)
- Felix H Savoie
- Department of Orthopaedic Surgery, Tulane University. 1430 Tulane Avenue, SL-32, New Orleans, LA 70112, USA.
| | - Michael O'Brien
- Department of Orthopaedic Surgery, Tulane University. 1430 Tulane Avenue, SL-32, New Orleans, LA 70112, USA
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Holt JB, Pedowitz JM, Stearns PH, Bastrom TP, Dennis MM, Dwek JR, Pennock AT. Progressive Elbow Magnetic Resonance Imaging Abnormalities in Little League Baseball Players Are Common: A 3-Year Longitudinal Evaluation. Am J Sports Med 2020; 48:466-472. [PMID: 31801034 DOI: 10.1177/0363546519888647] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies have revealed magnetic resonance imaging (MRI) evidence of elbow pathology in single-season evaluation of competitive youth baseball players. The natural history of these findings and risk factors for progression have not been reported. PURPOSE To characterize the natural history of bilateral elbow MRI findings in a 3-year longitudinal study and to correlate abnormalities with prior MRI findings, throwing history, playing status, and physical examination. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A prospective study of Little League players aged 12 to 15 years was performed. All players had preseason and postseason bilateral elbow MRI performed 3 years before this study. Players underwent repeat bilateral elbow MRI, physical examination, and detailed assessment of throwing history, playing status, and arm pain. Imaging was read by a blinded musculoskeletal radiologist and compared with prior MR images to assess for progression or resolution of previously identified pathology. RESULTS All 26 players who participated in the previous single-season study returned for a 3-year assessment. At the completion of the study, 15 players (58%) had dominant arm MRI pathology. Eighty percent (12/15 players) of MRI findings were new or progressive lesions. Players with postseason MRI pathology at the beginning of the study were more likely to have MRI pathology at the 3-year follow-up than players with previously normal postseason MRI (P < .05), although 6 of the 14 players (43%) with previously normal MRI developed new pathology. Year-round play was a significant predictor of tenderness to elbow palpation (P = .027) and positive MRI findings at 3 years (P = .047). At the 3-year follow-up, 7 players (27%) reported having throwing elbow pain and 3 had required casting. Additionally, differences were noted in the dominant arm's internal and external rotation in those that continued to play baseball (P < .05). CONCLUSION Dominant elbow MRI abnormalities are common in competitive Little League Baseball players. Year-round play imparts significant risk for progression of MRI pathology and physical examination abnormalities.
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Affiliation(s)
- Joshua B Holt
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA
| | - Jason M Pedowitz
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, California, USA
| | - Philip H Stearns
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA
| | - Tracey P Bastrom
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA
| | - M Morgan Dennis
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA
| | - Jerry R Dwek
- Department of Radiology, Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- Pediatric Orthopedics & Scoliosis Center, Rady Children's Hospital, San Diego, California, USA.,Department of Orthopedic Surgery, University of California, San Diego, San Diego, California, USA
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39
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The Curse of the All-Star Team: A Single-Season Prospective Shoulder MRI Study of Little League Baseball Players. J Pediatr Orthop 2020; 40:e19-e24. [PMID: 30994580 DOI: 10.1097/bpo.0000000000001391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Throwing guidelines have been implemented in Little League baseball in an attempt to minimize injuries in young baseball players. We hypothesized that playing pitcher or catcher and increased innings played during the season would result in dominant shoulder magnetic resonance imaging (MRI) abnormalities. METHODS A prospective evaluation of Little League players aged 10 to 12 years was performed. Players recruited before the start of the season underwent bilateral preseason and dominant shoulder postseason MRI, physical examination, and questionnaires addressing their playing history and arm pain. Innings played, player position, pitch counts, and all-star team selection were recorded. RESULTS In total, 23 players were enrolled. The majority (19/23, 82.6%) were right-handed and 16 of 23 (69.6%) played at least 10 innings as pitcher or catcher. Sixteen were selected for the all-star team. Fourteen players (60.9%) had positive dominant shoulder MRI findings not present in their nondominant shoulder. Eight players (34.8%) had new or worsening postseason MRI findings. Thirteen players (81.3%) selected to the all-star team had abnormal MRI findings whereas only one (14.3%) player not selected as an all-star had MRI abnormalities (P=0.005). Year-round play (P=0.016), innings pitched (P=0.046), innings catcher (P=0.039), and number of pitches (P=0.033) were associated with any postseason MRI abnormality, but not for new or worsening MRI changes. Single sport athletes and players playing for multiple teams were significantly more likely to have abnormal MRI findings (P=0.043 and 0.040, respectively) when compared with multisport athletes playing on a single team. CONCLUSIONS MRI abnormalities involving the dominant shoulder are common in Little League baseball players and often develop or worsen during the season. Contrary to our hypothesis, MRI abnormalities were not associated with player position and pitch counts. Instead, they were most closely associated with year round play, single sports participation, and all-star team selection. The increased demands required for all-star selection comes at a price to the young athlete as the majority of players selected for this honor had abnormal MRI findings in their throwing shoulder while few non all-stars demonstrated such pathology. LEVEL OF EVIDENCE Level II.
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40
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Jang SH. Management of Ulnar Collateral Ligament Injuries in Overhead Athletes. Clin Shoulder Elb 2019; 22:235-240. [PMID: 33330225 PMCID: PMC7714305 DOI: 10.5397/cise.2019.22.4.235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022] Open
Abstract
Ulnar collateral ligament injuries of the elbow are frequent among overhead athletes. The incidence of ulnar collateral ligament reconstructions (UCLRs) in high-level players has increased dramatically over the past decade, but the optimal technique of UCLR is controversial. Surgeons need to manage the patients’ expectations appropriately when considering the mode of treatment. This article reviews current studies on the management of ulnar collateral ligament injuries, particularly in overhead athletes.
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Affiliation(s)
- Suk-Hwan Jang
- Department of Orthopedic Surgery, Sports Medicine Research Institute, Inje University Seoul Paik Hospital, Seoul, Korea
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41
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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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Raducha JE, Gil JA, Harris AP, Owens BD. Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete. JBJS Rev 2019; 6:e1. [PMID: 29406433 DOI: 10.2106/jbjs.rvw.17.00061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UPDATE This article was updated on February 26, 2018, because of a previous error. On pages 1 and 7, in the author byline section, the authors' names that had read "Andrew Harris" and "Brett Owens" now reads "Andrew P. Harris" and "Brett D. Owens."
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Affiliation(s)
- Jeremy E Raducha
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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43
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Jordan D, Schimoler P, Kharlamov A, DeMeo PJ, Miller MC. Correlation of Force to Deformation of the Anterior Bundle of the Medial Collateral Ligament Through Consideration of Band Laxity. J Orthop Res 2019; 37:2027-2034. [PMID: 31081556 DOI: 10.1002/jor.24344] [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: 11/28/2018] [Accepted: 04/23/2019] [Indexed: 02/04/2023]
Abstract
The anterior bundle of the medial collateral ligament (AMCL) resists the loads that arise at the elbow during overhand throwing and has commonly been divided into posterior and anterior bands. While these anterior and posterior bands have been thought to bear the load at different flexion angles, any transition of the load distribution between the two bands is poorly understood and has not considered laxity (slack). This study considers the AMCL as three bands and quantifies the mechanical response to vertical distraction, simulating valgus-load joint opening, through the sequential superposition of the band responses after the elimination of inherent laxity. Eight cadaveric elbow specimens were used for the study. The intact AMCL of each specimen was tested under vertical distraction in a specialized load frame at four elbow flexion angles and then subsequently retested after two longitudinal transections. The greatest laxity at full extension and full flexion belonged to the posterior (1.9 mm) and anterior (2.4 mm) band, respectively. At the lesser and higher flexion angles, the greatest structural stiffness belonged to the anterior and middle band. The overall AMCL was the most structurally stiff at 60°, with approximately 150 N of force required for 2% elongation. This study shows that the different bands of the AMCL may have different load bearing properties at different flexion angles, causing each band to support different proportions of an imposed load. The presence of the laxity may impose a load-bearing delay, causing load-bearing in each band to begin asynchronously. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2027-2034, 2019.
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Affiliation(s)
- David Jordan
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick Schimoler
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania.,Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Alexander Kharlamov
- Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Patrick J DeMeo
- Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
| | - Mark Carl Miller
- Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania.,Orthopaedic Surgery, Allegheny General Hospital, 10th Floor, S. Tower, 320 E. North Avenue, Pittsburgh, Pennsylvania, 15212
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44
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Dubin JM, Rojas JL, Borade AU, Familiari F, McFarland EG. Isolated complete ulnar collateral ligament tear of the elbow in a gymnast: does it need surgery? PHYSICIAN SPORTSMED 2019; 47:242-246. [PMID: 30827129 DOI: 10.1080/00913847.2019.1589104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ulnar collateral ligament (UCL) tears can occur from trauma or chronic overuse, and the treatment depends on the type of sport the patient plays and the severity of symptoms. Overuse UCL injuries are most commonly due to micro-trauma in overhead athletes such as baseball players, softball players, and tennis players. Acute complete UCL tears in athletes due to trauma are less common but generally operative treatment is recommended. In gymnastics, elbow dislocations are more common than isolated UCL injuries, and there is sparse literature on the success of non-operative treatment of isolated UCL injuries in this group of athletes. In this case report, we report a high-level competitive gymnast with an UCL tear and a partial tear of the forearm flexor mass, which was confirmed by a thorough careful physical examination and magnetic resonance imaging. The patient was treated non-operatively and successfully returned to gymnastics without symptoms. This case supports the suggestion that UCL tears of the elbow can be treated successfully in some gymnasts without surgery, and that treatment should be individualized in this group of athletes.
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Affiliation(s)
- Justin M Dubin
- The Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University , Baltimore , MD , USA
| | - Jorge L Rojas
- The Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University , Baltimore , MD , USA
| | - Amrut U Borade
- The Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University , Baltimore , MD , USA
| | - Filippo Familiari
- The Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University , Baltimore , MD , USA
| | - Edward G McFarland
- The Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University , Baltimore , MD , USA
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45
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Foruria AM, Gutiérrez B, Cobos J, Haeni DL, Valencia M, Calvo E. Most coronoid fractures and fracture-dislocations with no radial head involvement can be treated nonsurgically with elbow immobilization. J Shoulder Elbow Surg 2019; 28:1395-1405. [PMID: 30956143 DOI: 10.1016/j.jse.2019.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 12/19/2018] [Accepted: 01/06/2019] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Conservative treatment of isolated coronoid fractures and fracture-dislocations focused on soft-tissue healing can provide good clinical results in the majority of patients. Our aims were (1) to evaluate the outcome of a conservative treatment protocol designed for isolated coronoid fractures with or without associated elbow dislocations (ICFs) and (2) to characterize the fractures with a dedicated image analysis protocol. METHODS Of 38 consecutive patients sustaining acute ICFs, 28 were treated nonsurgically after meeting specific inclusion criteria, prospectively followed up, and clinically evaluated at least 1 year after sustaining their injuries. All cases underwent elbow computed tomography scans with tri-plane and 3-dimensional reconstructions according to a specific protocol referenced to the proximal ulna. RESULTS The study included 15 male and 13 female patients, with a mean follow-up period of 32 ± 14 months (range, 12-61 months). An associated dislocation was presented in 8 (29%). Mean extension and flexion were 2° ± 8° (range, -10° to 30°) and 139° ± 11° (range, 110°-155°), respectively. Mean pronation and supination were 74° ± 3° (range, 60°-75°) and 83° ± 9° (range, 40°-85°), respectively. Of the patients, 78% rated their elbow as being normal or nearly normal. The mean Mayo Elbow Performance Score was 95 ± 9 (range, 70-100). The mean Disabilities of the Arm, Shoulder and Hand score was 7 ± 13 (range, 0-57). The mean coronoid fracture height was 5.7 ± 1.2 mm (range, 3.7-7.9 mm). The mean percentage of coronoid height fractured was 33% ± 6% (range, 23%-43%). Mean fracture displacement was 2.7 ± 2 mm (range, 1-9 mm). Of the fractures, 23 (82%) were located at the anteromedial coronoid. CONCLUSION An ICF with a perfectly reduced ulnohumeral joint, a competent sublime tubercle, and a fractured coronoid height up to 50% can be treated without surgery with excellent or good results in more than 90% of cases regardless of the location of the fracture in the coronoid or the type of soft tissue-associated disruptions.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain.
| | - Begoña Gutiérrez
- Muscle-Skeletal Radiology Unit, Radiology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Jesús Cobos
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - David L Haeni
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Maria Valencia
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Emilio Calvo
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery and Trauma Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery. J Orthop Sports Phys Ther 2019; 49:253-261. [PMID: 30862273 DOI: 10.2519/jospt.2019.8215] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Injuries to the elbow in athletes who play overhead sports, especially in baseball pitchers, continue to increase in frequency. The anterior band of the ulnar collateral ligament (UCL), the primary restraint to valgus stress, is commonly injured from throwing. Historically, such injuries have been treated with surgical reconstruction techniques, using a tendon autograft. A recently developed UCL repair procedure with an internal brace, utilizing collagen tape, is gaining popularity. The primary goal of this surgery is to enhance elbow joint stability while the ligament is healing and to allow earlier return to sport after UCL reconstruction. The rehabilitation program following UCL repair with internal brace progresses through a different time frame than after UCL reconstruction. The purpose of this commentary, based on our experience with more than 350 cases, including 79 patients with at least a 1-year postsurgical follow-up, was to describe and provide the rationale for the rehabilitation process following UCL repair with internal brace. J Orthop Sports Phys Ther 2019;49(4):253-261. doi:10.2519/jospt.2019.8215.
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47
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Millard N, DeMoss A, McIlvain G, Beckett JA, Jasko JJ, Timmons MK. Wrist Flexion Exercise Increases the Width of the Medial Elbow Joint Space During a Valgus Stress Test. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:959-966. [PMID: 30280397 DOI: 10.1002/jum.14779] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The medial elbow is stabilized during valgus loading by the ulnar collateral ligament, the flexor pronator mass (FPM), and the radial head. Impairment of the FPM can occur as a result of repeated wrist flexion activity. The purpose of this study was to determine the effect of repeated elbow flexion exercise on medial elbow stability. METHODS Thirty volunteers were included in this study. Ultrasound images of the medial joint space of the nondominant elbow of the participants were collected during a valgus stress test. The images were collected before and immediately after a wrist flexion exercise protocol. RESULTS The wrist flexion strength measure decreased (7.5%) after the exercise protocol (t = 3.840; P = .001). The medial elbow width increased between unstressed (mean ± SD, 2.8 ± 0.1 mm) and stressed (3.6 ± 0.1 mm) conditions (P < .001). The stress-by-fatigue interaction was significant (P = .048). The medial elbow width increased after fatigue (0.9 ± 0.09 mm) while remaining unchanged in the unstressed condition. CONCLUSIONS This study found an effect of repeated wrist flexion exercise on decreasing the stability of the medial elbow. Future research needs to explore the mechanisms leading to the decrease in medial elbow stability and to identify the effect of FPM fatigue on the development of medial elbow pain associated with activities.
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Affiliation(s)
- Nathaniel Millard
- College of Health Professions, Marshall University, Huntington, West Virginia, USA
| | - Andrew DeMoss
- College of Health Professions, Marshall University, Huntington, West Virginia, USA
| | - Gary McIlvain
- College of Health Professions, Marshall University, Huntington, West Virginia, USA
| | - Joseph A Beckett
- College of Health Professions, Marshall University, Huntington, West Virginia, USA
| | - John J Jasko
- Department of Orthopedics, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
| | - Mark K Timmons
- College of Health Professions, Marshall University, Huntington, West Virginia, USA
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48
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Abstract
PURPOSE OF REVIEW Injury to the ulnar collateral ligament is the most common, significant injury affecting the medial elbow of the overhead athlete. However, there are many other significant sources of pathology that should be considered. This review seeks to present a broad range of conditions that providers should consider when evaluating the overhead athlete with medial elbow pain. RECENT FINDINGS Recent biomechanical studies have deepened understanding of the anatomy and function of the anterior bundle of the ulnar collateral ligament germane to the overhead athlete. Orthobiologics hold potential for expanding the role of non-operative treatment for ulnar collateral ligament injuries. In addition to injury to the ulnar collateral ligament, providers should be prepared to diagnose and treat valgus extension overload, proximal olecranon stress fracture, ulnar nerve pathology, common flexor - pronator mass injury, and, in adolescents, medial epicondylar avulsion, when managing medial elbow pain in the overhead athlete.
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Affiliation(s)
- L Pearce McCarty
- Sports & Orthopaedic Specialists, part of Allina Health, 8100 W 78th Street, Suite 225, Edina, MN, 55439, USA.
- Department of Orthopaedic Surgery, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN, 55407, USA.
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49
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Kadri OM, Okoroha KR, Patel RB, Berguson J, Makhni EC, Moutzouros V. Nonoperative Treatment of Medial Ulnar Collateral Ligament Injuries in the Throwing Athlete. JBJS Rev 2019; 7:e6. [DOI: 10.2106/jbjs.rvw.18.00031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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50
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Arner JW, Chang ES, Bayer S, Bradley JP. Direct Comparison of Modified Jobe and Docking Ulnar Collateral Ligament Reconstruction at Midterm Follow-up. Am J Sports Med 2019; 47:144-150. [PMID: 30500269 DOI: 10.1177/0363546518812421] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The modified Jobe and docking techniques are the 2 most commonly employed techniques for ulnar collateral ligament (UCL) reconstruction among overhead athletes. However, no study has directly compared these techniques performed by a single surgeon. Current comparisons of these techniques have relied solely on systematic reviews and biomechanical studies. HYPOTHESIS There will be no difference in outcomes or return to play between the modified Jobe and docking techniques in elbow UCL reconstruction surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Twenty-five modified Jobe and 26 docking UCL-reconstructive surgical procedures were performed by a single surgeon, each with a minimum 2-year follow-up. Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Conway Scale, years played, sex, handedness, sport, position, palmaris versus gracilis graft type, concomitant or future arm/shoulder injuries, and need for additional surgery were compared between the groups. Patients who underwent future shoulder or elbow surgery, no matter the cause, were included. RESULTS No difference was seen between the modified Jobe and docking reconstruction cases in regard to KJOC scores (mean ± SD: 78.4 ± 19.5 vs 72.0 ± 26.0, P = .44), Conway Scale (return to play, any level: 84% vs 82%, P = .61), years played (14.7 ± 6.2 vs 15.2 ± 5.8, P = .52), sex ( P = .67), handedness ( P ≥ .999), sport ( P = .44), position ( P = .60), level of competition ( P = .59), and future surgery (12% vs 4%, P = .35). Palmaris graft type had significantly higher KJOC scores than hamstring grafts (82.3 ± 20.0 vs 57.9 ± 21.2, P = .001). The mean follow-up was 6.1 years in the modified Jobe group and 7.3 years in the docking group (mean = 6.7, P = .47). CONCLUSION The modified Jobe and docking techniques are both suitable surgical options for elbow UCL reconstruction. There was no statistically significant difference between the techniques in regard to return to play, KJOC score, or need for subsequent surgery at 6.7-year follow-up. This is the first direct clinical comparison of these 2 techniques by a single surgeon at midterm follow-up.
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Affiliation(s)
- Justin W Arner
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Stephen Bayer
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James P Bradley
- Burke and Bradley Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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