Ulnar Collateral Ligament Reconstruction: The Rush Experience

Return to play after UCL injury in gymnasts

BACKGROUND

Injuries to the ulnar collateral ligament (UCL) are commonly reported in traditional overhead sports. Conversely, there is a lack of evidence outlining management and return to play (RTP) outcomes for gymnasts. This study aimed to evaluate RTP and patient reported outcomes (PROs) in gymnasts after operative and non-operative treatment of UCL injuries.

METHODS

Gymnasts who presented with UCL injury and underwent operative and non-operative treatment were evaluated. Patient reported outcomes were collected via telephone: Conway-Jobe Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) Score, Mayo Elbow Performance (MEP) Score, and quick DASH (qDASH) and Timmerman-Andrews (TA) Elbow Score.

RESULTS

Nine patients met inclusion criteria and were available for follow-up. Five were initially treated operatively and four were initially treated non-operatively. The operative group initially consisted of three ulnar collateral ligament reconstructions (UCLR) and two UCL repairs with internal bracing. One patient crossed over to the operative group after failing non-operative treatment and underwent UCLR four months post injury. Overall, 66.7% and 100% of operatively and non-operatively treated gymnasts were able to return to play, respectively. At final follow-up, the operative groups' mean KJOC, MEP, TA, and qDASH scores were: 68.4 ± 7.7, 97.5 ± 2.7, 90.8 ± 10.7, and 1.9 ± 3.0, respectively. For the non-operative group, the mean scores were 67.4 ± 9.0, 71.7 ± 5.8, 71.7 ± 14.4, and 11.4 ± 9.9, respectively. Treatment satisfaction for the operative group was 81.7 ± 27.5 compared to 80.6 ± 34.5 in the non-operative group. Odds ratios indicated no differences between groups.

CONCLUSION

Both operative and non-operative interventions for UCL injuries in gymnasts can provide favorable outcomes with respect to return to play and subjective patient-reported outcomes. Further research is warranted to determine optimal treatment, especially regarding indications for operative vs. nonoperative treatment, of UCL injury based on injury severity and location in gymnasts.

LEVEL OF EVIDENCE

Case series; Level III Evidence.

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents

BACKGROUND

Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies.

PURPOSE

To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

An institutional review board-approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions.

RESULTS

A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions (P = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears (P < .001).

CONCLUSION

UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.

Workload Risk Factors for Pitching-Related Injuries in High School Baseball Pitchers

BACKGROUND

Pitch counts are only one measure of the true workload of baseball pitchers. Newer research indicates that workload measurement and prevention of injury must include additional factors. Thus, current monitoring systems gauging pitcher workload may be considered inadequate.

PURPOSE/HYPOTHESIS

The purpose of this study was to develop a novel method to determine workload in baseball pitchers and improve processes for prevention of throwing-related injuries. It was hypothesized that our pitching workload model would better predict throwing-related injuries occurring throughout the baseball season than a standard pitch count model.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This prospective observational study was conducted at an academic medical center and community baseball fields during the 2019 to 2023 seasons. Pitchers aged 13 to 18 years were monitored for pitching-related injuries and workload (which included pitching velocity; intensity, using preseason and in-season velocity as a marker of effort; and pitch counts).

RESULTS

A total of 71 pitchers had 313 recorded pitcher outings, 11 pitching-related injuries, and 24,228 pitches thrown. Gameday pitch counts for all pitchers ranged from 19 to 219 (mean, 77.5 ± 41.0). Velocity ranged from 46.8 to 85.7 mph (mean, 71.3 ± 5.8 mph). Intensity ranged from 0.7 to 1.3 (mean, 1.0 ± 0.08). The mean workload was 74.7 ± 40.1 for all pitchers. Risk factors significant for injury included throwing at a higher velocity in game (P = .001), increased intensity (eg, an increase in mean velocity thrown from preseason to in-season; P < .001), and being an older pitcher (P = .014). No differences were found for workload between injured and noninjured pitchers because the analysis was underpowered.

CONCLUSION

Our workload model indicated that throwing at a higher velocity, throwing at a higher intensity, and older age were risk factors for injury. Thus, this novel workload model should be considered as a means to identify pitchers who may be at greater risk for injury.

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.

Twisting technique for ulnar collateral ligament reconstruction of the elbow: new possibilities toward enhancing the strength of autografts

Background

Although the ulnar collateral ligament reconstruction procedure has been increasing in popularity annually owing to its stable postoperative outcomes, the number of revision surgeries following ulnar collateral ligament reconstruction has increased. The success of the initial reconstruction surgery and further improvement in the return-to-play rates of the initial surgery are crucial. In this study, we report on ulnar collateral ligament reconstruction using the twisting technique, which aims to enhance the strength of the graft (palmaris longus tendon) to improve return-to-play rates.

Methods

We investigated the return-to-play rate and period in 60 cases (2016-2021) that underwent ulnar collateral ligament reconstruction using the twisting technique and 211 cases (2007-2019) that did not use the twisting technique. The twisting technique involved inserting the graft through the bone tunnel and then twisting the doubled tendon.

Results

According to the Conway-Jobe scale, the twisting technique group had 98.3% excellent, 1.7% good, 0% fair, and 0% poor results, with a mean return-to-play period of 9.8 months. The non-twisting technique group had 86.7% excellent, 9.0% good, 1.9% fair, and 2.4% poor results, with a mean return-to-play period of 11.4 months. The two groups showed significant differences in return-to-play rate (P = .020) and period (P = .022).

Conclusion

The clinical results of the twisting technique showed that the return-to-play rate of the twisting technique group was higher after than before the procedure, and the return-to-play period was shortened by more than 1 month. The twisting technique may improve the results of ulnar collateral ligament reconstruction surgery.

Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis

BACKGROUND

Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique.

RESULTS

Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003).

CONCLUSIONS

Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, systematic review of Level IV studies.

Clinical Outcomes After Ulnar Collateral Ligament Reconstructions With Concomitant Ulnar Nerve Transposition in Overhead Athletes: A Matched Cohort Analysis

BACKGROUND

Injury of the ulnar collateral ligament (UCL) has become increasingly common, particularly in overhead athletes. There is no consensus on management of the ulnar nerve in UCL reconstruction (UCLR) in patients with preoperative ulnar nerve symptoms, as literature supports both not decompressing the nerve as well as ulnar nerve transposition (UNT).

HYPOTHESIS/PURPOSE

The purpose of this study was to compare subjective clinical outcomes and return-to-sports (RTS) metrics between patients who received UNT during UCLR and a matched cohort who underwent UCLR alone. We hypothesized that there would be no significant difference in patient outcomes or RTS metrics between the cohorts.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Using an institutional database, patients who underwent UCLR with UNT between 2007 and 2017 were retrospectively identified. These patients were matched based on sex, age at surgery (±3 years), and body mass index (±2 kg/m²) to a comparison group that underwent UCLR alone. Patients completed the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, the Timmerman and Andrews elbow score, the Conway-Jobe scale, and custom patient satisfaction and RTS questionnaires.

RESULTS

Thirty patients who underwent UCLR with concomitant UNT and 30 matched patients who underwent UCLR without UNT were available for follow-up at a mean of 6.9 (3.4-9.9) and 8.1 (3.4-13.9) years, respectively. The UNT group reported similar KJOC (78.4 in UNT vs 76.8; P = .780), Conway-Jobe (60% excellent in UNT vs 77% excellent; P = .504), Timmerman and Andrews (86.2 in UNT vs 88.8; P = .496), and satisfaction scores (85.3% in UNT vs 89.3%; P = .512) compared with UCLR group. In terms of RTS rate (84% in UNT vs 93% in UCLR; P = .289) and duration required to RTS (11.1 months in UNT vs 12.5 months in UCLR; P = .176), the 2 groups did not significantly differ. Finally, despite significant differences in preoperative ulnar nerve symptoms (100% in UNT vs 7% in UCLR; P < .001), the 2 groups did not statistically differ in the proportion of patients who experienced postoperative ulnar nerve symptoms (13% in UNT vs 0% in UCLR; P = .112).

CONCLUSION

This matched cohort analysis showed no statistically significant differences in patient-reported outcomes and RTS between patients undergoing UCLR with and without UNT.

Ulnar Collateral Ligament Reconstruction with Hamstring Autograft

Background:

Ulnar collateral ligament (UCL) reconstructions have become increasingly common, particularly in youth overhead throwing athletes. These injuries are most commonly due to overuse and repetitive trauma on the inner elbow. Throwers with a deficient UCL often report decreased pitching speeds in addition to elbow pain and instability.

Indication:

The indications for this procedure include symptomatic valgus elbow instability during overhead throwing motions and a verified rupture of the UCL on advanced imaging.

Technique Description:

The ipsilateral gracilis tendon is harvested and prepared as an autograft. A 5-cm incision is then made centered over the medial epicondyle. The ulnar nerve is identified and neurolysis is performed both proximally and distally. The fascia overlying the flexor carpi ulnaris is incised, and the two heads of the muscle are split. From this base, the sublime tubercle is identified, and the UCL is opened longitudinally in line with its fibers. A standard guide is used to drill holes in the posterior and anterior aspects of the sublime tubercle. These holes are then connected using a curved curette, and a suture is passed along the tunnels for later graft passage. A 15-mm blind-end tunnel is drilled two-thirds from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with K-wires to pass sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is then passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is then undertaken so that both ends are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the two limbs of the graft are sutured together to appropriately tension the graft.

Results:

In our experience, 94% of athletes return to previous levels of play and experience high patient-reported outcome scores.

Discussion/Conclusion:

Advancements in UCL reconstruction techniques and our understanding of elbow anatomy should prompt surgeons to continue considering this treatment for patients with significant throwing pain and a strong desire to return to high levels of throwing.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Ulnar Collateral Ligament Tears: A Modified Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements on the treatment of UCL injuries and to investigate whether consensus on these distinct topics could be reached.

METHODS

A modified consensus technique was conducted among twenty-six elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90-99% agreement.

RESULTS

Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus.

CONCLUSION

There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and prior injury. There was unanimous agreement that advanced imaging in the form of either an MRI or MRA should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of non-operative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for RTS were regarding: portions of the physical exam should be considered when determining whether to allow a player to RTS, unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS.

LEVEL OF EVIDENCE

Expert opinion (Level V).

Hypertrophy of the sublime tubercle in elbow ulnar collateral ligament injuries: a case series of baseball pitchers undergoing ulnar collateral ligament reconstruction with short-term follow-up

Background

The ulnar collateral ligament (UCL) of the elbow is subject to repetitive stress in overhead throwing athletes. This can lead to morphologic changes at the bony attachments of the UCL and hypertrophy of the sublime tubercle. The purpose of this case series is to describe the surgical details and clinical outcomes of a series of competitive baseball pitchers with hypertrophic sublime tubercles who underwent UCL reconstruction (UCLR).

Methods

All baseball pitchers who were treated for UCL injuries with significant hypertrophy of the sublime tubercle on preoperative imaging were included in the series. Clinical history, preoperative imaging, intraoperative findings during UCLR, and postoperative outcomes measured with the Conway scale were described.

Results

Ten players (average age of 22.9 years [range 13-39]) were included (average follow-up 20.4 months [range 3-38 months]). Five patients also had symptoms of ulnar nerve compression, with 4 requiring transposition at the time of ULCR and 1 at 3 months postoperatively. Bony hypertrophy of the sublime tubercle was confirmed intraoperatively in all cases and excised before UCLR with the docking technique. Of the 7 patients with at least 12-month follow-up postoperatively, 6 had excellent outcomes, and 1 had a fair outcome.

Conclusion

Although UCLR in the setting of hypertrophic sublime tubercle can be more complex than typical UCLR, excellent outcomes are achievable with preoperative recognition and surgical planning.

Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes

BACKGROUND

Ulnar collateral ligament (UCL) surgery continues to demonstrate excellent clinical outcomes and a high return-to-play (RTP) rate with a low complication rate. Recent studies have demonstrated similar clinical outcomes for baseball players who have undergone either UCL reconstruction or UCL repair. In comparison, few studies have assessed the clinical outcomes of UCL surgery for nonthrowing athletes.

PURPOSE/HYPOTHESIS

The primary objective of this study is to provide clinical outcomes of UCL surgery performed in nonthrowing athletes at a single institution with a minimum 2-year follow-up. Our hypothesis was that these patients would have similar clinical outcomes, complication rates, and RTP rates when compared with throwing athletes.

LEVEL OF EVIDENCE

Case series; Level of evidence, 4.

METHODS

From our longitudinal elbow registry, 40 nonthrowing athletes were identified who underwent UCL surgery (repair or reconstruction) between 2011 and 2019. Participant characteristics were recorded: age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included RTP rate and average time, American Shoulder and Elbow Surgeons (ASES) scores, and complications.

RESULTS

From the 40 patients eligible for inclusion in this study with a minimum 2-year follow-up, 37 (93%) were successfully contacted: 16 male (43%) and 21 female (57%). Mean ± standard deviation age at the time of surgery was 18.0 ± 3.7 years. From the 37 technical procedures, 28 (76%) were UCL repairs and 9 (24%) were UCL reconstructions. For these patients, 15 (41%) had partial tears, 20 (54%) had complete tears, 1 (3%) had a medial epicondyle avulsion, and 1 (3%) had an unspecified pathology. Sports included football (n = 11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients, as quarterbacks are throwing athletes. Level of competition included high school (n = 26), college (8), professional (2), and youth sports (1). The RTP rate was 93% (26/28) at a mean 7.4 months for UCL repair and 100% (9/9) at a mean 10.0 months for UCL reconstruction. Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively. Complications were low, with 2 patients in the UCL repair group requiring ulnar nerve transposition for ulnar nerve paresthesia.

CONCLUSION

In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. RTP and clinical outcomes are consistent with previous studies in baseball players as well as a parallel ongoing study conducted on non-baseball throwing athletes.

Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique

BACKGROUND

Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously.

METHODS

Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque.

RESULTS

Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P = .002). The DDA mean cyclic stiffness was significantly greater than the Native (P < .001), DD (P = .025), and MD (P < .001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51° ± 1.59°) and least for the DDA group (1.01° ± 0.57°) but did not reach statistical significance.

CONCLUSION

Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.

Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review

BACKGROUND

Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR.

HYPOTHESIS

There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate.

RESULTS

Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR.

CONCLUSION

Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.

Return-to-Competition Criteria After Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Injury to the ulnar collateral ligament of the elbow is common among overhead throwing athletes and can result in significant functional limitations. While surgical reconstruction offers high rates of return to competition, there are no validated or universally accepted guidelines for determining when an athlete can safely resume play.

PURPOSE

To assess the existing scientific literature for return-to-competition criteria utilized after ulnar collateral ligament reconstruction.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

The PubMed database was searched for clinical investigations of ulnar collateral ligament reconstruction in overhead throwing athletes published between January 2000 and June 2020. Only studies that had a minimum follow-up of 1 year and included at least 1 specific return-to-competition criterion were considered.

RESULTS

A total of 15 studies were included in the final analysis, encompassing 1156 patients with an average age of 20.7 years (SD, 2.0 years). Baseball players composed 96.3% of patients for whom sport was specified, and 92.4% of baseball players were pitchers. The most common return-to-competition criterion, identified in 87% of studies, was completion of a return-to-throwing program, which started on average 16.7 weeks (range, 12-18 weeks) after surgery. A return-to-mound program was utilized in 53% of studies, starting on average 7.4 months (range, 6-9 months) postoperatively. Minimum time from surgery was used in 73% studies, with players waiting 7 to 12 months (mean, 9.7; SD, 1.4 months) after surgery before return-to-competition consideration. The overall rate of return to competition at the preinjury level or higher was 85.7% (SD, 8.5%) at an average of 12.2 months (SD, 0.6 months).

CONCLUSION

In general, we observed a paucity of literature describing the return-to-competition process after ulnar collateral ligament reconstruction in overhead throwing athletes. Only 3 explicit return-to-competition criteria were identified across all studies: completion of a return-to-throwing program, completion of a return-to-mound program for pitchers, and minimum time from surgery. Increased transparency regarding postoperative rehabilitation protocols and further research are necessary to identify and validate sport-specific return-to-competition criteria, which will ultimately help athletes return to play in a safe and timely fashion after ulnar collateral ligament reconstruction.

Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes

BACKGROUND

Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers.

PURPOSE

To report outcomes after UCLR in javelin throwers.

HYPOTHESIS

UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports.

METHODS

All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications.

RESULTS

Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery.

CONCLUSION

UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.

Modulation of the PI3K/Akt/mTOR signaling pathway by probiotics as a fruitful target for orchestrating the immune response

The mammalian target of rapamycin (mTOR) and the phosphatidylinositol-3-kinase (PI3K)/protein kinase B or Akt (PKB/Akt) signaling pathways are considered as two but somewhat interconnected significant immune pathways which play complex roles in a variety of physiological processes as well as pathological conditions. Aberrant activation of PI3K/Akt/mTOR signaling pathways has been reported to be associated in a wide variety of human diseases. Over the past few years, growing evidence in in vitro and in vivo models suggest that this sophisticated and subtle cascade mediates the orchestration of the immune response in health and disease through exposure to probiotics. An expanding body of literature has highlighted the contribution of probiotics and PI3K/Akt/mTOR signaling pathways in gastrointestinal disorders, metabolic syndrome, skin diseases, allergy, salmonella infection, and aging. However, longitudinal human studies are possibly required to verify more conclusively whether the investigational tools used to understand the regulation of these pathways might provide effective approaches in the prevention and treatment of various disorders. In this Review, we summarize the experimental evidence from recent peer-reviewed studies and provide a brief overview of the causal relationship between the effects of probiotics and their metabolites on the components of PI3K/Akt/mTOR signaling pathways and human disease.

Routine diagnostic arthroscopy with elbow ulnar collateral ligament reconstruction does not reduce the need for future valgus extension overload-related surgeries: a systematic review and meta-analysis

BACKGROUND

Valgus extension overload syndrome (VEOS) most commonly affects overhead athletes and consists of a constellation of conditions involving the medial, posterior, and lateral elbow, with the most widely discussed being ulnar collateral ligament (UCL) injuries. Many athletes with UCL tears also have findings consistent with other VEOS conditions, though these are not consistently symptomatic. Given the high rate of concomitant pathology, many authors have recommended performing arthroscopy at the time of UCL reconstruction (UCLR) to diagnose and address concomitant VEOS pathology; however, it is not known if this practice actually leads to a reduction in subsequent surgeries for VEOS conditions following index UCLR. The purpose of this systematic review and meta-analysis was to determine if performing routine diagnostic arthroscopy (RDA) in patients undergoing UCLR was associated with a lower incidence of future VEOS-related surgery.

METHODS

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with the primary outcome of interest being the likelihood of needing future surgery to address VEOS conditions with or without RDA at the time of index UCLR. The proportion and incidence rate of subsequent VEOS-related surgeries following UCLR with and without RDA were compared in mixed effects models.

RESULTS

There were 25 eligible studies from an initial 1335 systematically identified articles, with results for 2118 UCLR cases. Among these, there were a total of 94 reported VEOS-related surgeries. The proportion of subsequent VEOS-related surgeries was lower when UCLR was performed with RDA (0.40%, 95% CI 0.00%-3.51%) than without (1.16%, 95% CI 0.03%-3.25%), but the difference was not significant (P = .584). The incidence rate of VEOS-related surgeries was 0.16 (95% CI 0.00-0.95) per 100 person-years with RDA and 0.14 (95% CI 0.00-0.55) per 100 person-years without RDA (P = .942).

CONCLUSION

RDA preceding UCLR does not significantly reduce the proportion or rate of subsequent surgery for other VEOS conditions. There has been a decrease in RDA utilization with UCLR over time for athletes with torn/incompetent UCLs but otherwise no known symptomatic VEOS conditions, and this trend appears to be justified based on these findings.

Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition

Background:

Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis.

Purpose:

To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis.

Study Design:

Case series; Level of evidence, 4.

Methods:

Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire.

Results:

Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively.

Conclusion:

This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Return-to-Sport Outcomes After Primary Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Tendon Grafts: A Systematic Review

Background

Ulnar collateral ligament (UCL) reconstruction is the current gold standard of treatment for overhead athletes with a symptomatic, deficient UCL of the elbow who have failed nonoperative treatment and wish to return to sport (RTS) at a high level. The palmaris longus and hamstring tendons are common graft choices, but no study has analyzed the existing literature to assess whether one graft is superior to the other.

Purpose

To systematically report on the outcomes of UCL reconstruction using palmaris and hamstring autografts.

Study Design

Systematic review; Level of evidence, 4.

Methods

A combination of the terms "ulnar collateral ligament," "valgus instability," "Tommy John surgery," "hamstring," and "palmaris longus" were searched in PubMed, Embase, and the Cochrane Library. RTS and return-to-same-level (RSL) rates, patient-reported outcomes, and complications were included for analysis. We used the modified Coleman Methodology Score and risk-of-bias tool for nonrandomized studies to assess the quality of the included studies.

Results

This review included 6 studies (combined total of 2154 elbows) that directly compared palmaris and hamstring graft use in UCL reconstruction. Follow-up ranged from 24 to 80.4 months, and the mean patient age across all studies was 21.8 years. The mean RSL across all studies and grafts was 79.0%, and the mean RTS was 84.1%, consistent with results previously reported in the literature. The mean RTS and RSL rates for the palmaris graft group were 84.6% and 82%, respectively; the hamstring graft group showed mean RTS and RSL rates of 80.8% and 80.8%. Meta-analysis revealed no significant difference in RSL between the 2 graft groups (odds ratio, 1.06; 95% CI, 0.77-1.46). The combined complication rate of the included studies was 18.2%, with failure rates ranging from 0% to 7.1%.

Conclusion

Results of this review indicated that both palmaris and hamstring tendon grafts are viable options for primary UCL reconstruction. Graft choice should be determined by a combination of patient and surgeon preference.

Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes

Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.

Postoperative Rehabilitation of Ulnar Collateral Ligament Reconstruction: A Systematic Review

The incidence of ulnar collateral ligament injuries has increased over the past few decades with greater participation in overhead throwing sports; however, optimal postoperative management following surgery remains unclear. This systematic review summarizes the latest evidence, on postoperative rehabilitation protocols for patients undergoing ulnar collateral ligament reconstruction (UCLR). Studies published in the English language from the year 2000 to 2019 with a level 1 to 4 grade of evidence and examined rehabilitation protocols following UCLR were eligible for inclusion. A multidatabase search was conducted. Two blinded reviewers screened and graded articles for inclusion and a third independent reviewer resolved any conflicts. Ten of the original 139 studies identified were used for analysis. Surgical techniques as well as rehabilitation protocols varied across studies. Analysis gave strong evidence that a 4-phase postoperative rehabilitation protocol utilizing milestone-based goals is effective in returning athletes back to preinjury levels of activity and sport within 1 year following UCLR.

Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review

IMPORTANCE

Tears of the ulnar collateral ligament (UCL) of the elbow occur predominantly as an overuse injury, most commonly affecting throwing athletes, particularly baseball players. UCL reconstruction (UCLR) has been described as an effective treatment modality in the short term.

OBJECTIVE

The purpose of this study was to systematically review the evidence in the literature to ascertain the clinical outcomes, complication and revision rates in baseball players following UCLR of the elbow at a minimum of 48 months of follow-up.

EVIDENCE REVIEW

Two independent reviewers performed a search of the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, PubMed and Scopus databases. Clinical studies were included if they reported outcomes of baseball players at a minimum of 48 months following UCLR.

FINDINGS

Our review included 8 studies including 1104 baseball players (1105 elbows) at mean 69.9 months (48-205) following UCLR. The majority of baseball players were pitchers (92.3%), with a mean age of 22.2 years (13-42). At final follow-up, the overall return to play (RTP) was 95.3%%, with 85.3% returning at pre-injury level. In addition, the mean reported Conway-Jobe score was 86.8%, the revision rate was 6.0% with postoperative neuropathy reported in 2.4% of patients. A total of 479 (43.4%) were professional baseball players, with an overall RTP rate of 97.5% and 82.3% managing to RTP at their pre-injury level. The mean number of career years following UCLR was 4.7 years (0-22).

CONCLUSION AND RELEVANCE

UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. In addition, high rates of RTP at pre-injury level and career longevity were reported by baseball players following UCLR.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis

Purpose

To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair.

Methods

A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ² tests were used to determine differences between group proportion categorical variables. Significance was considered at a P ≤ .05.

Results

From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South (P < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females (P < .01).

Conclusions

MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin.

Level of Evidence

IV, Therapeutic Case Series.

Ulnar Collateral Ligament Reconstruction in Adolescents: A Systematic Review

BACKGROUND

Ulnar collateral ligament (UCL) reconstruction is an established surgical technique to restore UCL deficiency, especially in the overhead throwing athlete. Over the past decade, the number of patients requiring UCL reconstruction has increased significantly, particularly in the adolescent patient population. Return-to-play rates after UCL reconstruction reported in the literature have ranged from 33% to 92%, and a recent systematic review noted a return-to-play rate of 89.40% in all high school athletes.

PURPOSE

To evaluate the outcomes, particularly return-to-play rates and subjective outcome scores, of UCL reconstruction of the elbow in adolescent throwing athletes.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was conducted via the electronic databases Embase, PubMed, and Cochrane. Studies that reported on outcomes, particularly return-to-play rates, in adolescent throwing athletes met the inclusion criteria and were included in our analysis. Studies that did not report on adolescent throwing athletes and studies that reported on adolescent throwing athletes but did not specify the return-to-play outcomes for these athletes were excluded from our analysis.

RESULTS

Nine studies met the inclusion criteria and were included in this review. There were 404 baseball players and 10 javelin throwers included in our analysis. A total of 349 of the 414 patients (84.30%) were successfully able to return to play at the same level of competition or higher. Successful rates of return to prior performance ranged from 66.67% to 91.49% in our analysis. Javelin throwers had a mean 80.00% rate of return to prior performance, while baseball players had a mean return-to-play rate of 84.40%. Complications were evaluated for 8 (88.9%) studies and 283 (68.4%) patients. There were 11 (3.9%) reported complications and 5 (1.8%) reoperations.

CONCLUSION

The findings of this systematic review revealed that adolescent patients are generally able to return to their preinjury level of performance or higher with limited complications. Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes.

Forearm flexor injury is associated with medial ulnar collateral ligament injury in throwing athletes

BACKGROUND

Elbow ulnar collateral ligament (UCL) injuries have become increasingly common in throwing athletes. The forearm flexors (FF) have been studied as biomechanical stabilizers for the medial elbow. However, there are no studies investigating the association of concomitant UCL injuries and FF injuries in throwing athletes.

OBJECTIVE

To determine if throwing athletes with a complete UCL injury had a greater likelihood of concomitant FF injury than those with a partial UCL injury.

DESIGN

Descriptive retrospective epidemiological study.

SETTING

Academic, tertiary care medical center.

PATIENTS

Throwing related UCL injuries in patients aged 12-24 years.

INTERVENTIONS/METHODS

Electronic medical records and key word searches identified all patients from January 1, 2010 to December 31, 2019. A board certified and fellowship trained musculoskeletal radiologist reviewed all advanced imaging studies.

RESULTS

Fifty-four patients (46 male, 8 female, mean age 17.1 years, SD 2.3) were included. Fifty-four UCL injuries (21 complete ruptures, 16 proximal partial injuries, 17 distal partial injuries) were confirmed by magnetic resonance imaging (MRI). Twenty-eight FF injuries (22 strains, 6 tears) were diagnosed with MRI and/or MRI-arthrogram. There was a significant association between sustaining a FF injury and UCL reconstruction (UCL-R) (X² = [1, N = 54], = 3.97, P = .046) (15/22, 68.2%), as well as FF injury and UCL injury location (X² = [1, N = 33], = 3.86, P = .049) (10/17, distal partial UCL injury, 58.8%). Analysis of FF injury and complete UCL tear is not significant (X² = [1, N = 54], = 3.02, P = .08) (14/21, 66.7%).

CONCLUSIONS

The data indicate that FF injury is associated with UCL injury in throwing athletes. Future prospective studies should investigate causation versus correlation of FF and UCL injury in throwing athletes. The results of this study have applications to multiple sports medicine areas that include but are not limited to surgical, nonsurgical, prehabilitation, rehabilitation, and sports performance. This study reveals a strongly significant association between FF injury and concomitant UCL injury in throwing athletes.

Effects of Mound Versus Flat-Ground Pitching and Distance on Arm Mechanics and Elbow Torque in High School Pitchers

Background:

Although the monitoring of a pitcher’s throwing arm workload has become a hot topic in both research and the pitching world, the impact of mound height and distance still remains unclear.

Purpose:

To compare the kinetics and kinematics between pitches from a mound and flat ground at 2 different distances.

Study Design:

Descriptive laboratory study.

Methods:

A total of 21 healthy high school varsity baseball pitchers (age, 16.2 ± 1.3 years; weight, 73.6 ± 11.0 kg; height, 181.3 ± 6.4 cm) participated in this study. Players were fitted with a motusBASEBALL sensor and sleeve. Each pitcher was instructed to pitch 5 fastballs under 4 conditions: mound at 60.5 ft (regulation distance), flat ground at 60.5 ft, mound at 50.5 ft, and flat ground at 50.5 ft. Linear mixed-effects models were used to account for both intra- and interplayer variability. A multivariable model was used to evaluate the association of mound pitching, flat-ground pitching, and their distances (50.5 ft and 60.5 ft), and their interaction to arm speed, arm slot, arm rotation, elbow varus torque, and ball velocity.

Results:

There were no statistically significant effects of mound, flat-ground, or distance variation on arm speed or shoulder rotation. Arm slot was significantly higher (+3.0°; P = .02) on pitches from the mound at 60.5 ft compared with 50.5 ft. Elbow varus torque was lower (–1.5 N·m; P = .02) on mound pitches at 60.5 ft compared with 50.5 ft. Pitches thrown from the mound displayed significantly faster ball velocity compared with flat-ground pitches at both distances (P < .01 for both), with pitches at 60.5 ft having higher velocity (+0.7 m/s; P < .01).

Conclusion:

Contrary to long-standing notions, the study results suggest that pitching from the mound does not significantly increase stress on the elbow compared with flat-ground pitching. Lower elbow varus torque and faster ball velocity at the regulation distance compared with the reduced distance indicate that elbow stress and ball velocity may not correlate perfectly, and radar guns may not be an appropriate surrogate measure of elbow varus torque.

Clinical Relevance:

A better understanding of the kinetic and kinematic implications of various throwing programs will allow for the designing of programs that are driven by objective data with aims directed toward injury prevention and rehabilitation in baseball pitchers.

Outcomes After Ulnar Collateral Ligament Revision Reconstruction in Baseball Players

BACKGROUND

There is a lack of evidence regarding the success of ulnar collateral ligament (UCL) revision reconstruction. Understanding outcomes after UCL revision reconstruction is important in clinical decision making for overhead athletes.

PURPOSE

To evaluate return to play and patient-reported outcomes after UCL revision reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients who underwent UCL revision reconstruction, attributed to retear of the ligament or pain, between June 2004 and July 2016 at 2 surgical centers were identified. Charts were reviewed for age, sex, date of primary and revision reconstruction, sport played, level of play, graft type, and complications. Patients were contacted by telephone to determine time to return to play, current level of participation, Conway score, Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, and satisfaction.

RESULTS

Of the 65 consecutive baseball players who underwent revision UCL reconstruction, 40 (62%) were contacted at a minimum 22 months after surgery. Of these, 38 (95%) were pitchers and 2 (5%) were position players. Time to return to throwing was 6.2 ± 2.3 months (mean ± SD), and the KJOC score was 74.2 ± 20.7. Based on the Conway score, 50% (20/40) had an excellent result, indicating a return to the previous competition level for at least 1 year, and 30% (12/40) had a good result, indicating a return to a lower level for at least 1 year. For those who were able to return to competition, it took 12.7 ± 3.6 months. In pitchers, 47% (18/38) returned to their previous competition levels for at least 1 year, with a KJOC score of 73.7 ± 21.1. Pitchers were able to return to throwing at 6.3 ± 2.3 months and competition at 12.8 ± 3.7 months.

CONCLUSION

Only half of baseball players undergoing UCL revision reconstruction were able to return to their previous levels of competition. Outcomes for revision reconstructions are not as promising as primary procedures. Baseball players should be cautioned that they may not return to their previous levels of play after a revision reconstruction.

Return to Sport and Sports-Specific Outcomes Following Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: A Systematic Review

BACKGROUND

The incidence of elbow injuries and ulnar collateral ligament (UCL) reconstruction in adolescent athletes is increasing. Knowledge and expectations of outcomes following this procedure are necessary for proper counseling and decision-making in this age group.

QUESTIONS/PURPOSES

We sought to report patient-reported outcomes, rate of return to sport, and rate of complications and reoperation following UCL reconstruction in adolescent athletes.

METHODS

A systematic review was conducted for adolescent athletes undergoing UCL reconstruction. The primary outcome measure was patient-reported outcome scores, specifically the Conway Scale, the Andrews-Timmerman score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) score. Secondary outcome measures included return to sport, rate of subsequent procedures, and complication rate. A descriptive analysis was performed.

RESULTS

Seven studies met the inclusion criteria. The average patient-reported outcome scores ranged from 81 to 87% (Conway, "excellent"), 83.6 to 92.7 (Andrews-Timmerman), and 76 to 89.3 (KJOC). The average rates of return to sport were 84% to preinjury level or higher, 93% to any level, and 57% to a higher level. Complication rates ranged from 0.7 to 11%. Rate of subsequent elbow procedures ranged from 0 to 10%.

CONCLUSIONS

This systematic review demonstrates favorable outcomes in adolescent athletes following UCL reconstruction. Patient-reported outcome scores and rates of return to sport were comparable with those reported in adult athletes. The procedure is not without risk of complications, and patients and parents should be counseled regarding this risk prior to surgery.

Ulnar Collateral Ligament Tear Location May Affect Return-to-Sports Rate but Not Performance Upon Return to Sports After Ulnar Collateral Ligament Reconstruction Surgery in Professional Baseball Players

BACKGROUND

The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS.

PURPOSE/HYPOTHESIS

The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears.

RESULTS

Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS (P = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits (P = .03), runs (P = .015), and walks (P = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups.

CONCLUSION

Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.

The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020

PURPOSE OF REVIEW

The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe's initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted.

RECENT FINDINGS

The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80-95%), the mean time to return to play (typically 12-18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.

The Role of Biologic Agents in the Non-operative Management of Elbow Ulnar Collateral Ligament Injuries

PURPOSE OF REVIEW

Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells.

RECENT FINDINGS

Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.

Comparison of Ulnar Collateral Ligament Reconstruction Techniques in the Elbow of Sports Players

Ulnar collateral ligament injuries have been increasingly common in overhead throwing athletes. Ulnar collateral ligament reconstruction is the current gold standard for managing ulnar collateral ligament insufficiency, and numerous reconstruction techniques have been described. Although good clinical outcomes have been reported regarding return to sports, there are still several technical issues including exposure, graft selection and fixation, and ulnar nerve management. This review article summarizes a variety of surgical techniques of ulnar collateral ligament reconstructions and compares clinical outcomes and biomechanics.

Imaging of the post-operative medial elbow in the overhead thrower: common and abnormal findings after ulnar collateral ligament reconstruction and ulnar nerve transposition

Ulnar collateral ligament (UCL) reconstruction is now being performed more commonly and on younger patients than in prior decades. As a result, radiologists will increasingly be asked to evaluate elbow imaging of patients presenting with pain who have had UCL reconstruction. It is essential for radiologists to understand the normal and abnormal imaging appearances after UCL reconstruction and ulnar nerve transposition, which is also commonly performed in overhead-throwing athletes. Doing so will allow radiologists to provide accurate interpretations that appropriately guide patient management.

Management of Ulnar Collateral Ligament Injuries in Overhead Athletes

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.

Anatomic and Biomechanical Evaluation of Ulnar Tunnel Position in Medial Ulnar Collateral Ligament Reconstruction

BACKGROUND

Although numerous techniques of reconstruction of the medial ulnar collateral ligament (mUCL) have been described, limited evidence exists on the biomechanical implication of changing the ulnar tunnel position despite the fact that more recent literature has clarified that the ulnar footprint extends more distally than was appreciated in the past.

PURPOSE

To evaluate the size and location of the native ulnar footprint and assess valgus stability of the medial elbow after UCL reconstruction at 3 ulnar tunnel locations.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen cadaveric elbows were dissected to expose the mUCL. The anatomic footprint of the ulnar attachment of the mUCL was measured with a digitizing probe. The area of the ulnar footprint and midpoint relative to the joint line were determined. Medial elbow stability was tested with the mUCL in an intact, deficient, and reconstructed state after the docking technique, with ulnar tunnels placed at 5, 10, or 15 mm from the ulnotrochlear joint line. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion-tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion.

RESULTS

The mean ± SD length of the mUCL ulnar footprint was 27.4 ± 3.3 mm. The midpoint of the anatomic footprint was located between the 10- and 15-mm tunnels across all specimens at a mean 13.6 mm from the joint line. Sectioning of the mUCL increased elbow valgus rotation throughout all flexion angles and was statistically significant from 30° to 100° of flexion as compared with the intact elbow (P < .05). mUCL reconstruction at all 3 tunnel locations restored stability to near intact levels with no significant differences among the 3 ulnar tunnel locations at any flexion angle.

CONCLUSION

Positioning the ulnar graft fixation site up to 15 mm from the ulnotrochlear joint line does not significantly increase valgus rotation in the elbow.

CLINICAL RELEVANCE

A more distal ulnar tunnel may be a viable option to accommodate individual variation in morphology of the proximal ulna or in a revision setting.

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

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.

UCL Injury in the Non-throwing Athlete

PURPOSE OF REVIEW

Primarily reported in the overhead throwing athlete, ulnar collateral ligament (UCL) injuries have been extensively studied since Dr. Frank Jobe first described his technique for ulnar collateral ligament reconstruction on professional baseball pitcher Tommy John. While the framework for our understanding of UCL injury was initially established studying the repetitive valgus loading of the throwers' elbow, other sport-related activities in non-throwing athletes can impart similar valgus stress on the medial elbow placing the UCL at risk for injury. The purpose of this review is to evaluate the current literature on UCL injury specifically in the non-throwing athlete.

RECENT FINDINGS

In the four decades since Dr. Jobe's seminal description of UCL reconstruction, an abundance of literature has been published on UCL injury in the throwing athlete. The evidence evaluating the UCL specifically in the non-throwing athlete, however, is quite scarce. Several small retrospective studies have demonstrated good results with high rates of return to play with focused rehabilitation and non-operative management in non-throwing athletes. Recent evidence has also demonstrated that surgical repair and/or reconstruction of the UCL in this population can produce good outcomes. The level of evidence of these published studies is low and consists primarily of case series without control groups. Further investigation is warranted to determine the optimal treatment algorithm for UCL injury in the non-throwing athlete.

Return to Play and In-Game Performance Statistics Among Pitchers After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review

BACKGROUND

Injury to the ulnar collateral ligament of the elbow is relatively common among baseball pitchers. Ulnar collateral ligament reconstruction (UCLR) has revolutionized the management of this injury, allowing a greater proportion of pitchers to return to play.

PURPOSE

To assess the return to play and in-game performance specific to baseball pitchers who have undergone primary UCLR.

STUDY DESIGN

Systematic review.

METHODS

This review was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies, and pertinent data were abstracted. Only studies reporting in-game performance statistics (earned run average [ERA], pitching velocity, innings pitched per season, etc) of pitchers after UCLR were included. The methodological index for nonrandomized studies (MINORS) was used to assess study quality.

RESULTS

A total of 14 studies and 1520 pitchers were included in this systematic review. All studies were of level 3 or 4 evidence, and the mean ± SD MINORS score was 14.4 ± 3.0, which indicates fair quality of evidence for nonrandomized studies. The rates of return to any level of pitching after UCLR ranged from 79% to 100%. Subgroup analysis revealed that 79% to 87% of Major League Baseball (MLB) pitchers returned to preinjury levels of pitching. The mean time to return to play was 19.8 ± 13.5 months, and the mean time to return to competition for MLB pitchers was 17.3 ± 2.4 months. Of the 5 studies reporting ERA, 2 cited a significant increase after UCLR, and 1 indicated a significant decrease. Of the 4 studies reporting fastball velocity, 3 cited decreased pitching velocities after UCLR. All studies found that pitchers pitched, on average, fewer innings per game or season after UCLR.

CONCLUSION

There was a high rate of return to pitching after UCLR. However, most studies showed that UCLR was associated with a prolonged recovery and significant decline in pitching performance as objectively measured by in-game statistics. The strength of these conclusions is limited by the quality of the available literature and inconsistencies in the reporting of outcomes.

Performance and Return to Sport After Open Reduction and Internal Fixation of the Olecranon in Professional Baseball Players

BACKGROUND

The results of open reduction and internal fixation (ORIF) of stress reactions and fractures of the olecranon among professional baseball players with regard to return to sport (RTS) are unknown.

PURPOSE/HYPOTHESIS

To determine the RTS rate and performance of professional baseball players after ORIF of acute, displaced olecranon fractures and olecranon stress fractures and to compare the RTS rate and performance with that of matched controls. The authors hypothesized that there is a high rate of RTS among professional baseball players after ORIF of acute, displaced olecranon fractures and olecranon stress fractures with no significant difference in rate of RTS or performance between cases and controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent ORIF of the olecranon between 2010 and 2016 were included. Demographic and performance data (before and after surgery) for each player were recorded. Performance metrics were then compared between cases and a group of matched controls.

RESULTS

Overall, 52 professional baseball players (mean ± SD age, 22.6 ± 3.6 years) underwent ORIF of an olecranon fracture. The majority of players sustained a primary olecranon stress fracture (73%) that was fixed with 1 screw (60%), with an overall RTS rate of 67.5%. No difference in RTS rate existed between matched controls and the cases. No significant difference existed between the primary pre- and postoperative performance metrics (ie, change in performance) for pitchers who underwent ORIF of an acute, displaced olecranon fracture or ORIF of a primary olecranon stress fracture. No significant difference existed between pitchers who underwent ORIF of a primary olecranon stress fracture and matched controls in any of the primary performance metrics. Three cases and 2 controls underwent ulnar collateral ligament reconstruction later in their careers after olecranon ORIF.

CONCLUSION

Professional baseball players who undergo ORIF of an olecranon fracture (acute, displaced, or stress) have an RTS rate of 67.5% (57.6% to the same or higher level), which is no different from natural attrition among matched controls. No decline in performance metrics was seen among players who were able to RTS when compared with their preoperative performance or the performance of matched controls.

Open Reduction Internal Fixation of Medial Epicondyle Fractures After Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

Background:

Ulnar collateral ligament reconstruction (UCLR) is a common procedure among professional baseball pitchers. An uncommon complication after UCLR is a fracture of the medial epicondyle at the level of the humeral tunnel, which requires open reduction internal fixation (ORIF).

Purpose/Hypothesis:

The purpose of this study was to determine the performance upon and rate of return to sport (RTS) in professional baseball pitchers after ORIF of the medial epicondyle and examine whether there is a difference in the RTS rate and performance between players who underwent ORIF and matched controls. It was hypothesized that there would be a high rate of RTS in professional baseball pitchers after ORIF of the medial epicondyle, with no difference between the ORIF and control groups in the rate of RTS or performance, specifically related to the primary performance outcome variables of win-loss percentage, walks plus hits per inning pitched, fielding independent pitching, and wins above replacement.

Methods:

All professional baseball pitchers who underwent ORIF of the medial epicondyle between 2010 and 2016 were included in this study. Demographic and performance data (preoperative and postoperative) were recorded for each player. Performance metrics were then compared between the ORIF and control (no history of UCLR or ORIF) groups.

Results:

Overall, 15 pitchers (80.0% starters, 73.3% right-handed) underwent ORIF of a medial epicondyle fracture. All had undergone prior UCLR using either the American Sports Medicine Institute (n = 9; 60.0%) or docking (n = 6; 40.0%) technique. ORIF techniques included fixation with 1 screw (n = 13; 86.7%) and fixation with suture anchors (n = 2; 13.3%). Eleven (73.3%) pitchers were able to return to sport (did not differ from controls; P = .537); 55% returned to the same level or higher. No significant differences existed in the primary performance outcome variables when comparing preoperative with postoperative performance. No significant differences in the primary performance outcome variables were seen between the ORIF and control groups after surgery, although players in the ORIF group pitched fewer innings than controls after surgery (P = .003).

Conclusion:

After ORIF of the medial epicondyle in professional pitchers with a history of UCLR, 73.3% were able to return to sport (only 55% of those who returned pitched at the same level or higher) without a significant decline in most performance variables when compared with their preoperative performance or matched controls. The number of innings pitched declined after surgery.

Do Outcomes or Subsequent Injuries Differ After Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Autograft?

BACKGROUND

Ulnar collateral ligament reconstruction (UCLR) is a successful procedure in professional baseball players. It is unclear whether graft choice affects results.

PURPOSE

Determine performance and rate of return to sport (RTS) in professional baseball players after UCLR and compare performance and RTS rate, as well as injury rates, between players who underwent UCLR with hamstring versus palmaris autograft.

HYPOTHESIS

A high RTS rate exists in professional baseball players after UCLR, with no significant difference in injury rates, RTS rates, or performance specifically related to primary outcome performance variables-WHIP ([walks + hits]/innings pitched), fielding independent pitching (FIP), and wins above replacement (WAR)-between those who undergo UCLR with palmaris versus hamstring autograft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball players who underwent UCLR with hamstring autograft between 2010 and 2015 were included. Surgical details were gathered from operative reports. Players with hamstring UCLR were compared with a matched control group of players who underwent UCLR with palmaris autograft.

RESULTS

Overall, 195 players underwent UCLR with hamstring autograft. No differences in RTS rates or timing to RTS were found between the hamstring and palmaris groups. Significantly more subsequent injuries to the contralateral lower extremity were seen in the hamstring group versus the palmaris group (25 vs 13, respectively) ( P = .040). More subsequent injuries to the upper extremity were found in the palmaris group versus the hamstring group (73 vs 55, respectively), although this difference was not significant ( P = .052). No consistent differences in performance metrics upon RTS existed between hamstring and palmaris groups, although both groups significantly declined in many performance metrics after surgery. Both hamstring and palmaris groups showed a decline postoperatively in WAR (0.86 vs 0.35 and 1.23 vs 0.34, respectively) and WHIP (1.33 vs 1.44 and 1.36 vs 1.51, respectively); FIP did not decline (4.56 vs 5.27 and 4.51 vs 4.53, respectively). No significant difference in WAR, WHIP, or FIP existed between groups postoperatively.

CONCLUSION

Baseball players who underwent UCLR with hamstring autograft were more likely to sustain a subsequent lower extremity injury, whereas those who underwent UCLR with palmaris autograft had a trend toward sustaining more upper extremity injuries. No difference in performance or RTS rates existed between groups. Both groups significantly declined in WAR and WHIP after UCLR.

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

BACKGROUND

Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring surgical reconstruction. Despite acceptable published return-to-play outcomes, multiple techniques and graft types have been described.

PURPOSE

This study compares UCL reconstruction (UCLR) outcomes based on tunnel configuration and graft type.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

After approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCLR between 2010 and 2014 were identified and included. The following patient characteristics were analyzed: age, pitching role (starter vs reliever), level of play (MLB vs Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique, graft type, and concomitant procedures. Primary outcome measures consisted of the ability to return to play at any level (RTP), ability to return to the same level of play (RSL), time to return, subsequent elbow injuries, and need for subsequent or revision elbow surgery. The effects of patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling.

RESULTS

The RTP rate was 79.9%, and the RSL rate was 71.2%. Grafts used to reconstruct the UCL included the palmaris longus autograft (n = 361, 63.7%), the gracilis autograft (n = 135, 23.8%), and other grafts (n = 70, 12.5%). Surgical techniques utilized were the docking technique (n = 171, 30.2%), the modified Jobe technique (n = 290, 51.2%), and other techniques (n = 105, 18.6%). There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the docking versus modified Jobe technique (80.1% vs 82.4%, respectively; P = .537) and for the 2 primary graft types (83.1% for palmaris longus vs 80.7% for gracilis; P = .596). The rate of subsequent elbow surgery was 10.5% for the docking technique versus 14.8% for the modified Jobe technique ( P = .203), and the rate of revision UCLR was 2.9% versus 6.2% for the docking versus modified Jobe technique, respectively ( P = .128). Significant trends toward an increasing use of the palmaris longus autograft ( P = .023) and the docking technique ( P = .006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP ( P < .001) and RSL ( P < .001), but they required a longer time to return (mean difference, 35 days; P = .039) and had a higher likelihood of subsequent elbow (odds ratio [OR], 3.58 [95% CI, 2.06-6.23]; P < .001) and forearm injuries (OR, 5.70 [95% CI, 1.99-16.30]; P = .004) but not subsequent elbow surgery. No specific variables correlated with the rates of subsequent elbow surgery or revision UCLR in the multivariate analysis. The use of concomitant ulnar nerve transposition did not affect outcomes.

CONCLUSION

Surgical outcomes in professional baseball players are not significantly influenced by UCLR technique or graft type. There was a high rate (46.3%) of subsequent throwing elbow injuries. MLB pitchers were more likely to RTP and RSL, but they had a higher frequency of subsequent elbow and forearm injuries than MiLB pitchers. Both the docking technique and the palmaris longus autograft are increasing in popularity among surgeons treating professional baseball players.

Side of Hamstring Harvest Does Not Affect Performance, Return-to-Sport Rate, or Future Hamstring Injuries After Ulnar Collateral Ligament Reconstruction Among Professional Baseball Pitchers

BACKGROUND

Ulnar collateral ligament reconstruction (UCLR) is a successful procedure among professional baseball pitchers. It is unclear if hamstring tendon harvest side for UCLR affects the outcome or alters the risk for subsequent hamstring injury.

HYPOTHESIS

Players with prior UCLR with ipsilateral (drive leg) hamstring autograft will have the same return-to-sport (RTS) rate and performance upon RTS but a higher number of subsequent lower extremity injuries than those with contralateral (landing leg) hamstring autograft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All players between 2010 and 2015 who underwent UCLR with hamstring autograft were included. Surgical details of their procedures were recorded from operative reports. Outcomes for UCLR with hamstring autograft harvested from the drive leg were compared with UCLR with the graft harvested from the landing leg.

RESULTS

Overall, 191 players underwent UCLR with hamstring autograft (drive leg, n = 58, 30%; landing leg, n = 133, 70%). The docking technique was more common in the drive leg group, while the figure-of-8 technique was more common in the landing leg group ( P > .001). More patients in the landing leg group underwent concomitant treatment of the ulnar nerve than the drive leg group ( P < .001). No difference existed in RTS rates or timing of RTS between groups. No differences in subsequent ipsilateral or contralateral hamstring injuries occurred between players who underwent UCLR with hamstring autograft from the drive leg or the landing leg ( P≥ .999 and P = .460, respectively). No difference in overall upper or lower extremity injury rates existed between groups (all P > .05), and no difference in performance metrics existed between groups upon RTS.

CONCLUSION

No difference in RTS rate, performance upon RTS, or subsequent injury rates (hamstring, lower extremity, or upper extremity) existed between players who underwent UCLR with hamstring autograft whether the graft came from the drive or the landing leg.

Approach to Medial Elbow Pain in the Throwing Athlete

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.

The Middle and Distal Aspects of the Ulnar Footprint of the Medial Ulnar Collateral Ligament of the Elbow Do Not Provide Significant Resistance to Valgus Stress: A Biomechanical Study

Background

The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown.

Purpose/Hypothesis

The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL.

Study Design

Descriptive laboratory study.

Methods

Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle.

Results

When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles.

Conclusion

The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load.

Clinical Relevance

This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.

Hamstring Injuries in Major League Baseball Pitchers: Implications in Graft Selection for Ulnar Collateral Ligament Reconstruction

BACKGROUND

Hamstring tendons are commonly harvested as autograft for ulnar collateral ligament reconstruction. There is no consensus in the literature whether the hamstring tendon should be harvested from the ipsilateral (drive) leg or contralateral (landing) leg of baseball pitchers undergoing ulnar collateral ligament reconstruction. Hamstring injuries commonly occur in baseball players, but there are no reports on their incidence specifically among Major League Baseball (MLB) pitchers, nor are there reports on whether they occur more commonly in the drive leg or the landing leg.

HYPOTHESIS

Hamstring injuries occur more commonly in the landing legs of MLB pitchers.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

MLB pitchers who sustained hamstring injuries requiring time spent on the disabled list were identified from publicly available sources over 10 seasons. Demographics of the pitchers and injury and return-to-sport data were collected. Hamstring injuries to the drive leg were compared with injuries to the landing leg.

RESULTS

Sixty-five pitchers had 78 disabled list stints due to hamstring injuries over 10 seasons. The landing leg was injured in 67.9% of cases, and the most common mechanism of injury was pitching. There were no significant differences in demographics between pitchers who sustained drive leg and landing leg injuries. There was no significant difference in mechanism of injury or time to return to sport between pitchers who sustained drive leg and landing leg injuries.

CONCLUSION

The landing leg is more commonly injured than the drive leg among MLB pitchers who sustain hamstring injuries. There is no difference in time to return to sport between pitchers who sustain drive leg and landing leg injuries. More research is required to determine whether there is a difference in performance or future injury between hamstring tendons harvested from the drive leg and the landing leg for ulnar collateral ligament reconstruction among pitchers.

Elbow Ulnar Collateral Ligament Reconstruction Using the Novel Docking Plus Technique in 324 Athletes

BACKGROUND

This retrospective case series examined 324 athletes who received elbow ulnar collateral ligament (UCL) reconstruction by a single surgeon in a private practice over a 9-year period. The novel Docking Plus technique for elbow UCL reconstruction in 324 athletes provided good or excellent Conway score results in 88% of patients. The preponderance of previous studies examining UCL reconstruction outcomes were performed by surgeons at one of only three institutions (Andrews Institute, Hospital for Special Surgery, Kerlan Jobe Orthopedic Clinic).

METHODS

Patients undergoing UCL reconstruction from November 2005 to December 2014 were identified and contacted with a mailed survey and phone call. These patients were given a subjective 19 question survey assessing their outcomes from surgery.

RESULTS

The participants who responded to our survey were 90% male and 77% baseball players, 73% of which were pitchers. Of the baseball players who responded, 51.9% were in high school at the time of their surgery, 37% college, 6.5% minor leagues, and 2.2% in Major League Baseball. After surgery, 36% of survey responders returned to a higher level of competition than previously. For example, a high school athlete who had UCL reconstruction and went on to pitch in college. Further, 45% returned to the same level, and 7% returned to a lower level. Subjective "satisfaction," was reported in 92% of responders and 97.2% reported that, "having surgery was a good idea." Symptom onset in the responding athletes was 58.9% sudden, and 41.1% gradual. Overall, 90.9% of respondents returned to play in less than 1.5 years while 6.3% never were able to return. Re-tear occurred in 2.5% of patients, while 8.8% had subjective nerve dysfunction for at least 3 months following surgery.

CONCLUSION

The Docking Plus technique can produce excellent subjective and objective results in athletes. Further study is warranted to see the effects of this procedure in other settings and determine which method of reconstruction or repair is superior.

Non-alcoholic Fatty Liver Disease Induced by Perinatal Exposure to Bisphenol a Is Associated With Activated mTOR and TLR4/NF-κB Signaling Pathways in Offspring Rats

Accumulating evidence suggests a role of bisphenol A (BPA) in non-alcoholic fatty liver disease (NAFLD), and its mechanism may be related to the up-regulation of lipogenic genes, but the mechanism of BPA induced lipogenic gene expression remains unknown. The aim of this study was to investigate the effects of perinatal exposure to BPA on NAFLD and its mechanisms. Pregnant Sprague-Dawley rats had access to drinking water containing 1 or 10 μg/ml BPA from gestational day 6 to post-natal day 21. For 5 weeks after weaning, offspring drank normal water without BPA. Body weight, lipid profile and the expression of genes or proteins involved in mTOR mediated lipid metabolism and autophagy, as well as inflammatory response were investigated in the 8-wk-old offspring of different genders. The results showed that body weight was increased only in females, however, males, and females from dams treated with BPA had significantly excess visceral adipose tissue, which was consistent with adipocyte hypertrophy. Elevated TG levels and up-regulation of lipogenic genes or proteins in liver, such as sterol regulatory element binding protein 1 (SREBP1), acetyl-CoA carboxylase 1 (ACC1), and fatty acid synthase (FAS) were consistent with increased liver lipid droplets in offspring exposed to BPA. Compared with controls, the protein levels of InsR, p-IRS-1, IRS-1, TSC1, and TSC2 were decreased, p-PI3K, p-Akt (S473), p-Akt (T308), p-mTOR, and mTOR were increased, and the impaired autophagic degradation was evidenced by increased protein levels of p62, although the levels of p-ULK1, Beclin1, and LC3B proteins were increased in liver of BPA-exposed offspring. The levels of TLR4 and NF-κB proteins were also significantly increased, and ERα protein was significantly decreased in BPA-exposed offspring. Our findings indicate that perinatal exposure to BPA causes the development of NAFLD in both female and male offspring, which is associated with up-regulation of lipogenic genes, dysregulated autophagy and activated inflammatory response involving the PI3K/Akt/mTOR and TLR4/NF-κB pathways.