Management of Ulnar Collateral Ligament Injuries in Overhead Athletes

Basic to advanced elbow arthroscopy: the history, basic set up, and indications

Elbow arthroscopy presents challenges; however, its indications and advantages over traditional open surgery are swiftly evolving. Despite being less widely performed than on other joints such as the knee, shoulder, ankle, and hip, arthroscopic management of the elbow has potential. The goals of this review are to describe and broaden the current applications of elbow arthroscopy. Additionally, we will provide insights and strategies to enhance the effectiveness of elbow arthroscopy.

A systematic review of the outcomes of partial ulnar collateral ligament tears of the elbow in athletes treated non-operatively with platelet-rich plasma injection

Background

This study aimed to analyze the effects of platelet-rich plasma (PRP) for partial ulnar collateral ligament (UCL) tears in athletes and predicted positive outcomes.

Methods

The researchers systematically reviewed the PubMed, Cochrane CENTRAL, MEDLINE, Scopus, and Google Scholar databases to identify studies with clinical outcomes of PRP for partial UCL tears. They excluded studies that did not stratify data by tear type or included surgical management.

Results

Five studies with 156 patients were included. The timing, amount, platelet concentration, type, and number of PRP injections were highly variable among the studies. However, 75% (n = 97/127) of athletes returned to sport (RTS) at a weighted average of 82.1 days (37-84) after PRP injection. One study showed significant improvements in patient-reported outcomes. Two studies showed positive outcomes in the modified Conway scale, complete reconstitution of the UCL in 87% of patients on MRI, and significant improvement in the humeral-ulnar joint space after PRP injection via ultrasound. The Coleman methodology score (CMS) averaged 48/100, indicating an overall poor quality of evidence.

Conclusion

This review demonstrates favorable RTS, clinical, and radiographic outcomes in patients receiving PRP for partial UCL tears, but the literature remains heterogeneous and of low quality.

Level of Evidence

III.

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.

Return to Sport After Ulnar Collateral Ligament Tears Treated with Platelet-Rich Plasma Injections is Influenced by Length of Rehabilitation and Leukocyte Content of Injections: A Systematic Review

PURPOSE

To analyze the current literature assessing return to sport (RTS) outcomes after platelet-rich plasma (PRP) injections for the nonoperative treatment of ulnar collateral ligament (UCL) injuries.

METHODS

A systematic review of PubMed, Embase, and Web of Science databases was conducted in June 2023 to identify studies assessing RTS after PRP injections for UCL injuries. Tear severity, leukocyte content of PRP, rehabilitation protocol, and RTS outcomes were collected. Heterogeneity was assessed through proportional random-effects models for RTS and return to preinjury level of play (RTLP) with subgroup analysis by rehabilitation length, leukocyte content of PRP, and tear severity.

RESULTS

Eight studies with 278 partial-thickness and 44 full-thickness tears were identified. The mean age of patients ranged from 17.3 to 26 years. The mean RTS time after injection ranged from 5.2 to 25.4 weeks. High heterogeneity was observed among studies, with RTS rates ranging from 46% to 100% (I2 = 83%) and RTLP rates ranging from 34% to 100% (I2 = 83%). Studies with the longest rehabilitation programs (12-14 weeks) had RTS rates of 87% to 100% (I2 = 0%). RTS rates among athletes treated with leukocyte-poor and leukocyte-rich PRP ranged from 73% to 100% (I2 = 30%) and 52% to 88% (I2 = 84%), respectively. Subanalysis of RTS by tear severity demonstrated high variability, with partial-thickness rates ranging from 59% to 100% (I2 = 55%) and full-thickness rates ranging from 27% to 100% (I2 = 63.2%).

CONCLUSIONS

Studies assessing RTS after PRP injections are highly heterogeneous; however, current data suggest nonoperative RTS and RTLP rates ranging from 46% to 100% and 34% to 100%, respectively. Studies with at least 12 weeks of rehabilitation and studies using leukocyte-poor PRP demonstrated low heterogeneity and greater RTS rates. Alternatively, high heterogeneity was observed among both partial- and full-thickness tears.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players

BACKGROUND

Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR).

PURPOSE

To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury.

RESULTS

The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P = .006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P = .030). Players of both groups had similar dominant UCL thickness (P = .161), ulnohumeral joint space at rest (P = .321), space under stress (P = .498), and laxity (P = .796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs -0.60 mm, respectively; P = .038) and a greater increase in relative median UCL thickness (1.35 vs -0.35 mm, respectively; P = .045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P = .004). No differences in ulnohumeral stress spacing or laxity were detected.

CONCLUSION

SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

From Dugout to the Mound: A Tale of Platelet-Rich Performance

Ulnar collateral ligament (UCL) tears of the elbow are prevalent injuries among throwing athletes and are associated with excessive or repeated valgus forces at the elbow. We present the case of an 18-year-old male baseball pitcher with an 18-month history of progressive right elbow pain, notably worsened during his fastball pitching. Clinical assessment revealed tenderness with dynamic stressing of the right UCL. Imaging analyses, including magnetic resonance imaging (MRI) and dynamic ultrasound, confirmed a high-grade partial tear of the UCL at its origin. Non-operative management was pursued, which included an ultrasound-guided platelet-rich plasma (PRP) injection and intensive physical therapy. Follow-up evaluations at six and 12 weeks demonstrated a noteworthy improvement in subjective pain descriptions and structural healing of the UCL. After the patient completed a therapy and rehabilitation program, throwing activities at full strength were able to be resumed. This case underscores the potential efficacy of conservative approaches in handling UCL tears with the inclusion of PRP as a viable treatment option.

Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

BACKGROUND

Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear.

PURPOSE

To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries.

RESULTS

A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757).

CONCLUSION

For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

Editorial Commentary: Diagnosis, Treatment, Rehabilitation and Return to Sport After Ulnar Collateral Ligament Injury: Agreement Does not Equal Consensus

Tommy John surgical reconstruction for ulnar collateral ligament injuries was first described by Frank Jobe in 1974. Although he estimated the chance for successful return very low, John, famous baseball pitcher, was able to return to play for another 14 years. Modern techniques and better understanding of anatomy and biomechanics have now resulted in a return-to-play rate of more than 80%. Ulnar collateral ligament injuries occur mainly in overhead athletes. Generally, partial tears can be treated nonoperatively, but in baseball pitchers, success rates are less than 50%. Complete tears often require surgery. Primary repair or reconstruction are feasible options, and the choice will depend not only on the clinical scenario, but also the surgeon. Unfortunately, the current evidence is not convincing, and a recent expert consensus study exploring diagnosis, treatment options, rehabilitation, and return to sports showed agreement among the experts, but not necessarily a consensus.

Mechanical properties and microstructural organization of common ulnar collateral ligament grafts: Palmaris longus and gracilis tendons

Ulnar collateral ligament (UCL) injuries are becoming increasingly common. The palmaris longus (PL) and gracilis (GR) tendons are the most common grafts used in UCL reconstructions. While clinical studies have demonstrated relatively similar outcomes for either graft, there is little quantitative data describing these grafts from a material perspective, specifically the mechanical and microstructural properties of these tissues and how they respond under dynamic loading. The purpose of this descriptive laboratory study was to quantify and compare the mechanical and microstructural properties of PL and GR tendons. A total of 13 PL and 11 GR cadaveric human tendons were obtained. Each specimen was divided into three subregions and subjected to preconditioning, ramp-and-hold stress-relaxation and ramp-to-failure testing. Mechanical parameters were computed for each sample, and a polarized light imaging technique was used to simultaneously evaluate dynamic microstructural properties during testing. The PL had larger toe- and linear-region modulus values than the GR. Within the GR, the distal subregion had stronger collagen alignment than the proximal subregion at the zero, transition and linear portions of the stress-strain curve. The PL and GR, have similar mechanical properties and similar microstructural alignment under load. The PL graft has similar properties throughout its length whereas the GR properties exhibited slight differences in strength of alignment along its length. The PL and GR exhibit larger moduli values and more strongly/uniformly aligned collagenous microstructure when qualitatively compared to data previously published on the native UCL.