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Jackson GR, Mowers CC, Sachdev D, Knapik DM, Lapica H, Sabesan VJ. 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. Arthroscopy 2024:S0749-8063(24)00262-7. [PMID: 38599535 DOI: 10.1016/j.arthro.2024.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024]
Abstract
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.
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Affiliation(s)
- Garrett R Jackson
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.
| | | | | | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, Chesterfield, Missouri, U.S.A
| | - Hans Lapica
- Department of Orthopaedic Surgery, Hospital Corporation of America, John F. Kennedy Hospital/University of Miami Miller School of Medicine, Lake Worth, Florida, U.S.A
| | - Vani J Sabesan
- Department of Orthopaedic Surgery, Hospital Corporation of America, John F. Kennedy Hospital/University of Miami Miller School of Medicine, Lake Worth, Florida, U.S.A.; Palm Beach Shoulder Service Atlantis Orthopaedics, Lake Worth, Florida, U.S.A
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Inagaki K, Ochiai N, Hashimoto E, Hattori F, Hiraoka Y, Ise S, Shimada Y, Ohtori S. Biomechanical Comparison of Stability and Strength After Ulnar Collateral Ligament Reconstruction With Suture Anchor Fixation Versus Bone Tunnels. Orthop J Sports Med 2023; 11:23259671231196135. [PMID: 37693807 PMCID: PMC10492499 DOI: 10.1177/23259671231196135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Ulnar collateral ligament (UCL) injuries occur frequently in baseball players, and UCL reconstruction is performed when nonoperative treatment fails. Purpose To compare a novel all-suture anchor method of UCL reconstruction with a method using bone tunnels (Ito method) by investigating the displacement against valgus torque and the failure strength. Study Design Controlled laboratory study. Methods Eight fresh-frozen cadaveric upper extremities (mean age, 82.0 years) were utilized in this study. To evaluate the displacement against valgus torque, the valgus stability test was performed for 4 anterior oblique ligament (AOL) conditions: intact AOL, resected AOL, reconstructed using the anchor method, and reconstructed using the Ito method. The load-to-failure test was performed to evaluate the failure strength of the anchor and Ito methods. Displacement against valgus load was compared between conditions using the repeated-measures 2-way analysis of variance with Bonferroni post hoc test, and failure strength between the anchor and Ito methods was compared using the unpaired t test. Results Displacements of the intact AOL and anchor method were significantly greater than those of the resected AOL at both 60° and 90° of flexion (intact AOL: P = .005 and P < .001, respectively; and anchor method: P = .024 and P < .001, respectively). The displacement of the Ito method at 90° of flexion was significantly greater than that of the resected AOL (P = .003), but no significant difference was observed at 60° of flexion (P = .109). There were no significant differences in displacement between the anchor and Ito methods at any flexion angle, nor was there a significant difference in failure torque between the anchor and Ito methods (16.3 ± 3.1 vs 17.6 ± 2.3 N·m, respectively; P = .537). Conclusion The displacement and failure strength against a valgus load after UCL reconstruction using a suture anchor on the ulnar side were equal to those using bone tunnels. Clinical Relevance UCL reconstruction using a suture anchor on the ulnar side is simpler and less invasive than using bone tunnels, with similar outcomes.
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Affiliation(s)
- Kenta Inagaki
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Nobuyasu Ochiai
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Eiko Hashimoto
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Fumiya Hattori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yu Hiraoka
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Shohei Ise
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Yohei Shimada
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University Hospital, Chiba, Japan
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Lynch JC, Johnson EE, Ciccotti MC, Erickson BJ, Dodson CC, Cohen SB, Ciccotti MG. Clinical Outcomes After Ulnar Collateral Ligament Reconstructions With Concomitant Ulnar Nerve Transposition in Overhead Athletes: A Matched Cohort Analysis. Am J Sports Med 2023; 51:919-925. [PMID: 36786243 DOI: 10.1177/03635465231152890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey C Lynch
- Department of Orthopaedics, Jefferson Health New Jersey, Stratford, New Jersey, USA
| | - Emma E Johnson
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | | | | | | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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Vaswani R, Fu MC, Dines JS, Boddapati V, Erickson BJ, LeBus GF, Papaliodis DN, Conway JE, Altchek DW. 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. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:513-519. [PMID: 37588466 PMCID: PMC10426510 DOI: 10.1016/j.xrrt.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
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.
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Affiliation(s)
- Ravi Vaswani
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Michael C. Fu
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Joshua S. Dines
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | | | | | - John E. Conway
- Department of Orthopaedic Surgery, UT Health McGovern Medical School, Houston, TX, USA
| | - David W. Altchek
- Hospital for Special Surgery, Sports Medicine Institute, New York, NY, USA
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Douthit C, Cox C, Chow N, Foster R, MacKay BJ. Bony hypertrophy of the forearm in bareback rodeo athletes. SAGE Open Med 2022; 10:20503121221077831. [PMID: 35223028 PMCID: PMC8874185 DOI: 10.1177/20503121221077831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Objective: Activities that require increased load bearing are known to cause bony hypertrophy. This phenomenon has been documented in the dominant arm of athletes in sports requiring significant utilization of a single limb. The literature addressing this effect in rodeo athletes, however, is minimal. Studies evaluating rodeo athletes are primarily focused on acute injury management rather than chronic symptoms resulting from changes in bone and soft tissue. We designed a study to evaluate bony hypertrophy in athletes without acute injury. Method: Rodeo bareback riders presented with frequent pain in their grip arm, no radiographic evidence of injury, and clinical signs of peripheral nerve compression. Anteroposterior and lateral X-rays taken for initial evaluation in 17 bareback rodeo athletes were retrospectively reviewed. The diameter of bilateral ulnas was measured at its longitudinal midpoint. Ratio of Ulnar Diameters (grip arm/free arm) and Percentage Diameter Difference were calculated. An independent samples t-test was used to assess differences in diameters of grip and non-grip arms. Result: The mean ulnar diameter was 18.4 ± 3.5 in the grip arm and 16.6 ± 3.5 in the non-grip arm ( p < 0.001). The mean ratio of grip to free arm ulnar diameter was 1.42 ± 0.21 (range = 1.05–1.92). The mean diameter percent difference measured 42.3% (range = 4.7%–92.0%), and the grip arm was observed to have a greater ulnar diameter compared to the non-grip arm. Conclusion: There are significant anatomic differences in the grip arm of bareback rodeo athletes compared to the contralateral arm. In cases of persistent pain in the grip arm and no evidence of acute injury, these differences may be relevant to pain symptoms and should be considered as part of the assessment and treatment algorithm.
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Affiliation(s)
| | - Cameron Cox
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Nathan Chow
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rick Foster
- Justin Sports Medical Team, Fort Worth, TX, USA
| | - Brendan J MacKay
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
- University Medical Center, Lubbock, TX, USA
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Bowers RL, Cherian C, Zaremski JL. A Review of Upper Extremity Peripheral Nerve Injuries in Throwing Athletes. PM R 2022; 14:652-668. [PMID: 35038233 DOI: 10.1002/pmrj.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/07/2022]
Abstract
Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be non-specific and frequent co-exist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical exam, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert L Bowers
- Assistant Professor of Rehabilitation Medicine, Emory University School of Medicine, Emory Sports Medicine Center, Atlanta, Georgia, USA
| | - Chris Cherian
- Department of Sports Medicine, Rothman Orthopaedics, Paramus, New Jersey, USA
| | - Jason L Zaremski
- Department of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery & Sports Medicine, University of Florida Health Orthopaedics and Sports Medicine Institute, Gainesville, Florida, USA
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De Giacomo AF, Keller RA, Banffy M, ElAttrache NS. Ulnar Neuritis and Its Affect on Outcomes of Elbow Ulnar Collateral Ligament Reconstruction. Am J Sports Med 2022; 50:224-228. [PMID: 34797176 DOI: 10.1177/03635465211053866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND No study has specifically evaluated how ulnar neuritis and ulnar nerve transposition affect outcomes in baseball players undergoing ulnar collateral ligament (UCL) reconstruction (UCLR). PURPOSE To evaluate the effects of ulnar neuritis and ulnar nerve transposition in baseball pitchers undergoing UCLR in regard to return to sport, time to return to sport, and need for revision or additional surgery. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS At a single institution, all consecutive baseball pitchers undergoing UCLR between 2002 and 2015 were identified. Ulnar neuritis was diagnosed preoperatively by the following criteria: ulnar nerve symptoms, Tinel sign at the elbow, symptomatic subluxation, and numbness/paresthesia in an ulnar nerve distribution of the hand. The primary outcome of the study was return to sport. The secondary outcomes of the study were time to return to sport, length of playing career, and revision or additional surgery. RESULTS A total of 578 UCLRs were performed in baseball players; of these, 500 UCLRs were performed in pitchers. Ulnar neuritis was diagnosed in 97 (19.4%) baseball pitchers presenting with UCL injury. There were no significant differences in patient characteristics or surgical techniques performed for reconstruction between baseball pitchers with and without ulnar neuritis. In review of injury characteristics, ulnar neuritis was significantly more likely to be diagnosed in pitchers with an acute onset of UCL injury (P = .03). Transposition of the ulnar nerve was more commonly performed in players with ulnar neuritis (47%) versus those without ulnar neuritis (10%; P = .0001). The players who had ulnar neuritis and underwent UCLR had a significantly lower odds of returning to sport (odds ratio, 0.45; P = .04); however, no significant difference was found for time to return to sport and length of playing career for those with and without ulnar neuritis (P = .38 and .51, respectively). CONCLUSION The study suggests that ulnar neuritis, when present preoperatively in baseball pitchers undergoing UCLR, may adversely affect their ability to return to sport, whereas ulnar nerve transposition at the time of UCLR does not alter the ability to return to sport.
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Affiliation(s)
| | - Robert A Keller
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Michael Banffy
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
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Rao S, D'Amore T, Willier DP, Gawel R, Jack RA, Cohen SB, Ciccotti MG. Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition. Orthop J Sports Med 2021; 9:23259671211055428. [PMID: 34881339 PMCID: PMC8646197 DOI: 10.1177/23259671211055428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022] Open
Abstract
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%.
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Affiliation(s)
- Somnath Rao
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Taylor D'Amore
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Richard Gawel
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Steven B Cohen
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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Hadley CJ, Dixit A, Kunkel J, White AE, Ciccotti MG, Cohen SB, Dodson CC. Return to play rates after ulnar nerve transposition and decompression surgery: a retrospective analysis. JSES Int 2021; 5:296-301. [PMID: 33681853 PMCID: PMC7910731 DOI: 10.1016/j.jseint.2020.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background Medial elbow pain is a common complaint in overhead throwing athletes. The throwing motion places repetitive tensile and compressive forces on the elbow resulting in significant stress across the ulnohumeral joint. This stress can result in soft-tissue, ligamentous, and ulnar nerve injury. The purpose of this study was to retrospectively investigate the clinical findings and outcomes, including return to play rates, of patients who underwent ulnar nerve transposition surgery for isolated ulnar neuritis. Methods Throwing athletes who underwent isolated, primary ulnar nerve transposition surgery over an eight-year period, 2009 to 2017, were identified and included in our analysis. Nonthrowing athletes, those who underwent revision ulnar nerve transposition surgery, and those who underwent concomitant ulnar collateral ligament reconstruction or repair were excluded. Patients were contacted to complete the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score as well as a return to play rate questionnaire. The minimum follow-up was 2 years. Results Fifteen patients met the inclusion criteria: 13 (86.7%) men and 2 (13.3%) women. The average age at the time of surgery was 19.2 years old (range, 15.6-28.0). Preoperatively, 13 (86.7%) patients played baseball and 2 (13.3%) patients played softball. Two patients (13.3%) underwent a previous ulnar collateral ligament reconstruction. There were no complications. The average final follow-up was 65.26 (range, 24.44-113.29) months with an average Kerlan-Jobe Orthopaedic Clinic Score of 64.51 (range, 28.60-100.00). Thirteen (86.7%) patients were able to return to their preinjury sport, 2 to a higher level of competition, 8 to the same level, and 3 to a lower level. Seven of the 13 (53.8%) patients sustained a postoperative ipsilateral shoulder or elbow injury at an average of 19.57 (range, 7.00-36.00) months postoperatively. All patients reported sustaining the injury as a result of throwing. Conclusion The results of our study indicate that ulnar nerve transposition surgery in throwing athletes allows athletes to return to throwing with low reoperation rates. However, more than half of the athletes in our analysis sustained a subsequent ipsilateral shoulder or elbow injury. Further investigation regarding outcomes in throwing athletes after ulnar nerve transposition surgery is warranted.
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Affiliation(s)
- Christopher J Hadley
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Anant Dixit
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Kaiser Permanente, Fontana, CA, USA
| | - John Kunkel
- Department of Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Alex E White
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Steven B Cohen
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher C Dodson
- Rothman Orthopaedic Institute at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Kakita M, Mikami Y, Ibusuki T, Shimoe T, Kamijo YI, Hoekstra SP, Tajima F. The prevalence of ulnar neuropathy at the elbow and ulnar nerve dislocation in recreational wheelchair marathon athletes. PLoS One 2020; 15:e0243324. [PMID: 33315922 PMCID: PMC7735619 DOI: 10.1371/journal.pone.0243324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Ulnar neuropathy at the elbow is an entrapment neuropathy, while ulnar nerve dislocation might also be involved in its incidence and severity. Wheelchair marathon athletes may be at an increased risk for Ulnar Neuropathy. However, there is a paucity of research into the prevalence of Ulnar Neuropathy and ulnar nerve dislocation in this population. OBJECTIVE To investigate the prevalence of ulnar neuropathy at the elbow and ulnar nerve dislocation in wheelchair marathon athletes. PARTICIPANTS Wheelchair marathon athletes (N = 38) who participated in the 2017, 2018, and 2019 Oita International Wheelchair Marathon. 2 athletes participated only one time, 36 athletes repeatedly. Data from athletes`latest assessment were used. METHODS The day before the race, questionnaires, physical examinations, and ultrasonography were conducted to screen for Ulnar Neuropathy in both upper limbs. Ulnar nerve dislocation was confirmed by physical examination and ultrasonography. RESULTS 11 (29%) athletes were diagnosed with Ulnar Neuropathy. There were no significant differences in age, height, weight, Body Mass Index, or history of primary illness between athletes with and without Ulnar Neuropathy. In the group without Ulnar Neuropathy, 44% of athletes reported to have been engaging in other wheelchair sports, compared to 9% in the group with Ulnar Neuropathy (p = 0.037). Ulnar nerve dislocation was diagnosed in 15 (39%) athletes by ultrasonography. Out of the 14 elbows of 11 athletes diagnosed with Ulnar Neuropathy, 9 (64%) elbows had ulnar nerve dislocation. CONCLUSION The prevalence of Ulnar Neuropathy in wheelchair marathon athletes was higher than previously reported in able-bodied, non-athlete individuals and lower than in non-athletes with lower limb dysfunction. Therefore, while wheelchair sports may provide some protection against Ulnar Neuropathy, this study further supports the importance of screening for Ulnar Neuropathy, as well as for ulnar nerve dislocation as a potential risk factor for the development of Ulnar Neuropathy.
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Affiliation(s)
- Mari Kakita
- Department of Rehabilitation Medicine, Kansai Electric Power Hospital, Osaka-City, Osaka-Prefecture, Japan
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
| | - Yukio Mikami
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
| | - Tatsuru Ibusuki
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
| | - Takashi Shimoe
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
| | - Yoshi-ichiro Kamijo
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
| | - Sven P. Hoekstra
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
- The Peter Harrison Centre for Disability Sport, Loughborough University, Loughborough, United Kingdom
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama-City, Wakayama-Prefecture, Japan
- The Peter Harrison Centre for Disability Sport, Loughborough University, Loughborough, United Kingdom
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11
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Abstract
PURPOSE OF REVIEW During overhead throwing, there are tremendous forces placed on the medial elbow that can result in injury to the ulnar nerve. The purpose of this article is to review the anatomy, biomechanics, and appropriate clinical care of an overhead throwing athlete suffering from injury to their ulnar nerve. The authors preferred clinical work-up; non-operative and operative care are included in this review. RECENT FINDINGS More recent findings support the use of subcutaneous transposition instead of the submuscular transpositions and only to perform a transposition in the setting of specific pre-operative findings. Subcutaneous transpositions have led to decreased rates of post-operative symptoms and complications. Understanding the complexity of the medial elbow is essential to making an accurate diagnosis of ulnar neuritis/neuropathy in the overhead throwing athlete. In general, non-operative management has shown to be successful; however, in those refractory or recurrent cases of ulnar neuritis, ulnar nerve decompression with or without transposition provides these athletes with a surgical procedure that has shown to provide patients with excellent outcomes. Continued refinement surgical indications and surgical technique will allow for a high percentage of athletes who return to competitive sports following surgery for ulnar neuropathy.
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Affiliation(s)
- S Blake Dowdle
- Department of Orthopaedics, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Peter N Chalmers
- Department of Orthopaedics, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA
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12
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Imaging of the post-operative medial elbow in the overhead thrower: common and abnormal findings after ulnar collateral ligament reconstruction and ulnar nerve transposition. Skeletal Radiol 2019; 48:1843-1860. [PMID: 31203406 DOI: 10.1007/s00256-019-03246-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 02/02/2023]
Abstract
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.
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13
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Leland DP, Conte S, Flynn N, Conte N, Crenshaw K, Wilk KE, Camp CL. Prevalence of Medial Ulnar Collateral Ligament Surgery in 6135 Current Professional Baseball Players: A 2018 Update. Orthop J Sports Med 2019; 7:2325967119871442. [PMID: 31598529 PMCID: PMC6764054 DOI: 10.1177/2325967119871442] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: As the incidence of ulnar collateral ligament (UCL) surgery continues to rise
rapidly, an update on the current prevalence and demographics in
professional baseball players is warranted. Hypothesis: The prevalence of UCL reconstruction in Major League Baseball (MLB) and Minor
League Baseball (MiLB) players will be higher than that previously reported,
and the increase in prevalence will be most notable in MiLB pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: During the 2018 baseball season, an online questionnaire regarding a history
of UCL surgery was distributed to the certified athletic trainers of all 30
MLB organizations. These trainers then administered the survey to all
players within their organizations, including MLB, MiLB (AAA, AA, High A,
Low A, High Rookie, Low Rookie), and Dominican Summer League (DSL) players.
Demographics were compared between MLB, MiLB, and DSL players. Results of
this 2018 survey were compared with previously published data from the 2012
season to assess the change over time. Results: There were 6135 professional baseball players who completed the survey (66%
response rate). The prevalence of UCL reconstruction in all MLB and MiLB
players was 13% (637/4928), while the prevalence in DSL players was 2%
(20/1207) (P < .001). The prevalence in all MLB and MiLB
players (13%) and pitchers (20%) both increased significantly from 2012
(P < .001). MLB pitchers reported a higher
prevalence of UCL reconstruction than did MiLB pitchers (26% vs 19%,
respectively; P < .001). In 2018, the prevalence of UCL
reconstruction has increased significantly in MiLB pitchers (19% vs 15%,
respectively; P < .001) and pitchers aged 21 to 30 years
(22% vs 17%, respectively; P < .001) compared with 2012.
Additionally, United States–born pitchers were more likely to have undergone
UCL reconstruction compared with Latin America–born pitchers (23% vs 13%,
respectively; P < .001). Conclusion: The prevalence of UCL reconstruction has increased significantly in
professional baseball players over the past 6 years from 10% to 13%.
Ultimately, the prevalence of UCL reconstruction has increased most
significantly since 2012 in MiLB pitchers, pitchers aged 21 to 30 years, and
pitchers born in the United States.
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Affiliation(s)
- Devin P Leland
- Departments of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stan Conte
- Conte Sport Performance Therapy, Phoenix, Arizona, USA
| | - Nancy Flynn
- Conte Injury Analytics, San Carlos, California, USA
| | | | | | - Kevin E Wilk
- Champion Sports Medicine, Birmingham, Alabama, USA
| | - Christopher L Camp
- Departments of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Molenaars RJ, van den Bekerom MPJ, Eygendaal D, Oh LS. The pathoanatomy of the anterior bundle of the medial ulnar collateral ligament. J Shoulder Elbow Surg 2019; 28:1497-1504. [PMID: 31028010 DOI: 10.1016/j.jse.2019.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to increase our understanding of the pathoanatomy of the ulnar collateral ligament (UCL) by performing a descriptive analysis of the surgical inspection of the anterior bundle in patients undergoing reconstruction. METHODS A single-surgeon series of 163 patients who underwent UCL reconstruction between 2009 and 2017 was retrospectively analyzed. Descriptions of the pathoanatomy of injury were obtained from the operative reports. Magnetic resonance imaging data were reviewed to assess whether the presence and location of tissue disruptions were accurately recognized. Demographic and clinical characteristics were obtained from medical records and correlated to observed pathoanatomy. RESULTS Injuries to the anterior bundle were characterized by a single tissue disruption (65%), tissue disruptions at more than 1 location (23%), or injuries without distinct fiber tissue disruptions (12%). The presence and location of tissue disruptions matched magnetic resonance imaging findings in 124 of 153 patients (81%). Partial tears more frequently affected the anterior band of the anterior bundle distally as opposed to the posterior band of the anterior bundle proximally (P = .012). Patients with single tissue disruptions more frequently reported a popping sensation than patients with non-tear insufficiency (P = .030). CONCLUSIONS This study shows the heterogeneity of anterior bundle injuries in patients undergoing UCL reconstruction. A variety of injury configurations and chronic attritional damage to the anterior bundle were observed, as well as distinct tear patterns at the distal and proximal attachment sites. Future research may elucidate the diagnostic value of a pop sign for UCL injury.
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Affiliation(s)
- Rik J Molenaars
- Sports Medicine Center, Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Joint Research, Department of Orthopedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Luke S Oh
- Sports Medicine Center, Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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15
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Abstract
PURPOSE OF REVIEW Injury to the ulnar collateral ligament is the most common, significant injury affecting the medial elbow of the overhead athlete. However, there are many other significant sources of pathology that should be considered. This review seeks to present a broad range of conditions that providers should consider when evaluating the overhead athlete with medial elbow pain. RECENT FINDINGS Recent biomechanical studies have deepened understanding of the anatomy and function of the anterior bundle of the ulnar collateral ligament germane to the overhead athlete. Orthobiologics hold potential for expanding the role of non-operative treatment for ulnar collateral ligament injuries. In addition to injury to the ulnar collateral ligament, providers should be prepared to diagnose and treat valgus extension overload, proximal olecranon stress fracture, ulnar nerve pathology, common flexor - pronator mass injury, and, in adolescents, medial epicondylar avulsion, when managing medial elbow pain in the overhead athlete.
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Affiliation(s)
- L Pearce McCarty
- Sports & Orthopaedic Specialists, part of Allina Health, 8100 W 78th Street, Suite 225, Edina, MN, 55439, USA.
- Department of Orthopaedic Surgery, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN, 55407, USA.
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16
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Chadwick N, Morag Y, Smith BW, Yablon C, Kim SM, Yang LJ. Imaging appearance following surgical decompression of the ulnar nerve. Br J Radiol 2018; 92:20180757. [PMID: 30359100 DOI: 10.1259/bjr.20180757] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ulnar neuropathy at the elbow is the second most common entrapment neuropathy of the upper extremity. Yet, there is a paucity of literature focusing on the imaging appearance following surgical decompression of the ulnar nerve at the elbow. Diagnostic imaging studies obtained after surgical decompression at The University of Michigan were reviewed and imaging findings were documented. We aim to describe the various techniques of ulnar nerve decompression and corresponding post-operative appearance on imaging. Potential complications following decompression will also be described with imaging and clinical correlation of recalcitrant ulnar neuropathy. It is important for the radiologist who performs MRI or ultrasound of the elbow to be aware of the various ulnar nerve decompression procedures. This knowledge will facilitate rapid and accurate diagnosis of normal and abnormal appearance of the ulnar nerve in this context.
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Affiliation(s)
- Nicholson Chadwick
- 1 Department of Radiology, University of Michigan, Musculoskeletal Imaging , Ann Arbor, MI , USA
| | - Yoav Morag
- 1 Department of Radiology, University of Michigan, Musculoskeletal Imaging , Ann Arbor, MI , USA
| | - Brandon W Smith
- 2 Department of Neurosurgery, University of Michigan , Ann Arbor, MI , USA
| | - Corrie Yablon
- 1 Department of Radiology, University of Michigan, Musculoskeletal Imaging , Ann Arbor, MI , USA
| | - Sung Moon Kim
- 1 Department of Radiology, University of Michigan, Musculoskeletal Imaging , Ann Arbor, MI , USA
| | - Lynda Js Yang
- 2 Department of Neurosurgery, University of Michigan , Ann Arbor, MI , USA
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17
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Reizner W, Rubin TA, Hausman MR. Cubital Tunnel Syndrome in the Athlete. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Fu MC, Camp CL, Altchek DW. Medial Ulnar Collateral Ligament Tears: Surgical Indications and Reconstruction Technique. OPER TECHN SPORT MED 2017. [DOI: 10.1053/j.otsm.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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