Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes

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

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

Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years

CONTEXT

Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management.

OBJECTIVE

This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation.

DATA SOURCES

Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022.

STUDY SELECTION

Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing.

RESULTS

Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores.

CONCLUSION

Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.

Ulnar Collateral Ligament Reconstruction Is Commonly Performed Using a Palmaris Graft and Provides Favorable Patient Outcomes With Variable Return-to-Play and Postoperative Complication Rates: A Systematic Review

PURPOSE

To systematically review the literature to provide an updated evaluation of postoperative clinical outcomes, return to play (RTP), and postoperative complications after primary ulnar collateral ligament reconstruction (UCLR) in throwing and nonthrowing athletes at minimum 2-year follow-up.

METHODS

A literature search was performed on November 25, 2023, by querying the Embase, PubMed, and Scopus online databases using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The inclusion criteria consisted of Level I to IV human clinical studies reporting postoperative outcomes and/or complications after primary UCLR with minimum 2-year follow-up. The exclusion criteria consisted of non-English-language studies; biomechanical, animal, and cadaveric studies; review articles; letters to the editor; and studies not reporting postoperative outcomes or complications. Study quality was evaluated using the Methodological Index for Non-Randomized Studies criteria. The incidence of reported complications among the included studies was extracted. Clinical outcome scores included the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, Andrews-Timmerman (AT) score, and satisfaction score. RTP data were also extracted.

RESULTS

A total of 21 studies published from 2006 to 2023, consisting of 2,452 patients (2,420 male patients) with a mean age of 21.7 years (mean range, 12-65 years) and mean follow-up period of 50.5 months (mean range, 24-151.2 months), were included. The mean Methodological Index for Non-Randomized Studies score was 16 (range, 13-20). A total of 46% of patients (1,138 of 2,452) underwent concomitant ulnar nerve transposition. Palmaris graft was the most frequently used method (66.6%; n = 1,799), followed by hamstring graft (26.0%, n = 703). At the final follow-up, mean postoperative KJOC scores ranged from 72.0 to 88.0; mean AT scores, from 83.6 to 98.3; and mean satisfaction scores, from 86.1 to 98.3. The overall RTP rate ranged from 62.5% to 100% at a mean range of 9.5 to 18.5 months. The total incidence of complications ranged from 0% to 31.8%, with 0% to 7.4% of patients undergoing revision surgery.

CONCLUSIONS

UCLR was commonly performed using a palmaris graft, with concomitant ulnar nerve transposition reported in 46% of patients. At a mean follow-up of 50.5 months, mean postoperative KJOC scores ranged from 72 to 98.3, AT scores ranged from 83.6 to 98.3, and satisfaction scores ranged from 86.1 to 98.3, with variable RTP rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Clinical Outcomes of Ulnar Collateral Ligament Repair With Internal Brace Versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes

BACKGROUND

The increasing prevalence of ulnar collateral ligament (UCL) injuries, particularly in young athletes, necessitates optimization of treatment options. The introduction of UCL repair with internal bracing offers an exciting alternative to traditional UCL reconstruction.

PURPOSE

To compare midterm outcomes between UCL repair with internal bracing and UCL reconstruction in competitive athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors identified competitive athletes who underwent primary UCL repair with internal bracing or UCL reconstruction between 2013 and 2021 and were at least 2 years postsurgery. To have qualified for repair, patients must have shown complete or partial UCL avulsion from the sublime tubercle or medial epicondyle. Relevant patient, injury, operative, and revision surgery data were collected via chart review. Preoperative American Shoulder and Elbow Surgeons Elbow assessment form (ASES-E), Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC), and Andrews-Carson scores were obtained from an ongoing data repository. ASES-E, KJOC, and Andrews-Carson scores, and return-to-sport (RTS) data were collected at follow-up. Linear regression modeling controlling for relevant covariates was utilized to compare patient-reported outcome (PRO) scores between groups. Proportions of athletes who successfully returned to sport and proportions of subsequent revision procedures between groups were compared using chi-square tests. Lastly, for those with baseline questionnaire data, the authors compared magnitude of change between preoperative and postoperative scores between groups using linear regression modeling with baseline scores and follow-up time as the covariates, and follow-up scores as the dependent variable.

RESULTS

A total of 461 athletes were eligible for inclusion with complete clinical and outcome data available (mean age at surgery, 19.1 years; 92% male). The UCL repair group had a significantly shorter follow-up time than the UCL reconstruction group (4.4 vs 6.3 years; P < .01). When controlling for follow-up time, the groups did not differ in ASES-E, KJOC, or Andrews-Carson scores at follow-up. There was no significant difference in proportion of revisions between UCL repair (9%) and UCL reconstruction (8%) (P = .77). Of the 268 athletes with complete follow-up in the repair group, 247 attempted to return to their preinjury sport, and 241 (98%) were able to RTS. Six athletes reported that they were unable to RTS due to limitations from their surgery. Of the 155 athletes with follow-up in the reconstruction group, 147 attempted to return to their preinjury sport; 145 (99%) were able to successfully RTS, and 2 were unable to return due to limitations from their surgery. The 2 groups, repair with internal brace versus reconstruction, did not statistically differ in the proportions that returned to preinjury sport (P = .20) but did differ regarding time in months to return to practice (6.7 ± 3.5 vs 10.2 ± 11.7) (P < .01) and time in months to return to competition (9.2 ± 4.6 vs 13.4 ± 13.3) (P < .01).

CONCLUSION

Athletes who underwent UCL repair with internal brace reported excellent midterm PROs statistically similar to those after UCL reconstruction, including proportion successfully returning to preinjury sport. There was no significant difference in revision rates between procedures. However, athletes who underwent UCL repair had a statistically significantly shorter time to RTS.

Favorable Outcomes Following Elbow Ulnar Collateral Ligament Reconstruction and Repair, Though Repair Associated with Increased Risk of Revision Surgery

PURPOSE

To assess the risk of revision surgery following repair versus reconstruction of the medial ulnar collateral ligament (UCL) of the elbow in a national sample of patients in the United States.

METHODS

This was a retrospective cohort study of young patients (≤35 years old) who underwent primary UCL reconstruction or repair for an isolated medial UCL injury of the elbow from October 2015 through October 2022 in a large national database (PearlDiver). Patient demographic data, comorbidities, surgical details, and concomitant ulnar nerve procedures were collected. Time-to-event analyses were used to assess the risk of revision UCL surgery between groups. Two-year complication rates, including ulnar neuropathy, were also assessed.

RESULTS

In total, 1,820 patients (69.9% reconstruction, 30.1% repair) with an average follow-up of 2.9 years met inclusion criteria. The estimated 2-year revision-free survival (95% confidence interval) was 99.5% (99.1%-99.9%) for UCL reconstruction compared to 97.9% (96.4%-99.3%) for UCL repair (unadjusted log-rank P = .032). UCL repair remained associated with an increased risk of revision UCL surgery after adjusting for confounding variables (hazard ratio, 2.94; 95% confidence interval, 1.07-8.09; P = .037). Complication rates were similar between reconstruction and repair, including the incidence of ulnar neuropathy (13.8% vs 14.5%, P = .78).

CONCLUSIONS

In this study, we found that UCL repair was associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample. Importantly, however, overall failure rates were low, and complication rates were similar between procedures. These findings support the overall favorable outcomes of UCL repair while suggesting it may not necessarily be the optimal treatment for all patients.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Management of Pediatric and Adolescent Sublime Tubercle Injuries: Isolated and Complex Patterns Demonstrate Distinct Etiologies and Radiographic Outcomes

BACKGROUND

The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries.

METHODS

A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected.

RESULTS

Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury).

CONCLUSIONS

This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes.

LEVEL OF EVIDENCE

Level IV-case series.