The ulnar collateral ligament response to valgus stress, repetitive pitching, and elbow muscle contraction in asymptomatic baseball pitchers.

Background: In baseball, repetitive pitching leads to medial elbow injuries, particularly to the ulnar collateral ligament (UCL). To prevent pitchers from UCL injuries, it is important to quantify the response to elbow stress. Repetitive elbow external valgus torque and muscular fatigue induced by repetitive pitching could affect markers of the response, that is, humeroulnar joint gap and UCL morphology. The aims of the study were three-folded: to investigate the effect of (1) exerted handgrip force on the humeroulnar joint gap, (2) repetitive pitching on the humeroulnar joint gap and the UCL morphology, and (3) exerted handgrip force on the humeroulnar joint gap for different levels of elbow valgus stress is different after compared to before repetitive pitching in asymptomatic baseball pitchers. Methods: Medial elbow ultrasound images were collected in 15 asymptomatic male baseball pitchers. Three levels of static elbow valgus stress (0N, 50N, 100N) were applied with a TELOS device before and after repetitive pitching and with or without handgrip force. These images were used to assess the humeroulnar joint gap size and UCL length and thickness. After 110 fastball pitches or when 80% self-perceived fatigue on a VAS scale was reached, participants were instructed to stop throwing. Repeated measures ANOVAs were used to statistically test significant differences. Results: Handgrip force did not significantly affect the humeroulnar joint gap. The UCL thickness and length and the humeroulnar joint gap were also not different after compared to before repetitive pitching. While higher levels of applied valgus stress significantly increased the humeroulnar joint gap (P < .001), this effect was not significantly different in the interaction with handgrip force and repetitive pitching. Conclusion: The humeroulnar joint gap changes for different levels of elbow valgus stress. However, adult baseball pitchers did not respond to elbow stress after a single pitching session with or without submaximal handgrip force in the humeroulnar joint gap and UCL morphology.

Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players.

Background: Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury. Purpose: To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position. Results: A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04). Conclusion: Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

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.

YouTube videos on ulnar collateral ligament reconstruction are highly variable in terms of reliability and quality: A quantitative analysis.

Background: Ulnar collateral ligament reconstruction (UCLR) is commonly performed on adolescent athletes, who often turn to online sources such as YouTube for health information. The purpose of this study was to retrospectively review the accuracy, reliability, and quality of UCLR videos using validated scoring instruments. Methods: YouTube was queried for "Tommy John surgery," "UCL reconstruction," and "ulnar collateral ligament reconstruction." After categorization by physician, nonphysician/trainer, patient or commercial source, videos were assessed for reliability and quality using the Journal of the American Medical Association (JAMA) benchmark criteria (0-4) and DISCERN tool (16-80). Results: 104 videos were included in the final analysis. 74% of videos (77/104) were made by physicians. The mean JAMA and DISCERN scores for all videos were 3.1 ± 0.8 and 46.1 ± 8.5, respectively. The majority of videos were rated as "fair" based on DISCERN score (56/104, 53.8%). JAMA scores were significantly higher for physician videos compared to nonphysician videos (3.3 ± 0.8 vs 2.6 ± 0.7, p < 0.0001), but no such difference was found for DISCERN scores (46.3 ± 7.7 vs 45.3 ± 10.57, p = 0.43). Conclusion: Physicians should be cognizant of the quality and reliability of YouTube videos when instructing patients on information sources related to UCLR.

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.

Arm injury in youth baseball players: a 10-year cohort study.

BACKGROUND: Arm injuries are commonly encountered in baseball as young athletes play into adulthood. The purpose of this study was to examine the incidence of arm injury and risk for surgery in adolescent baseball players followed over a 10-year period from scholastic, age-group, and travel baseball leagues through their highest level of competition. METHODS: A prospective study was conducted enrolling middle and high school baseball players in 2010-2012, then followed for 10 years or until retirement from competitive baseball. Players were included if fully participating in team activities at the time of preseason study enrollment. Players with prior arm (shoulder or elbow) surgery or those diagnosed with time loss arm injury within the past year were excluded. Only shoulder and elbow overuse problems resulting in time-loss from sport and medical attention from a sports medicine physician or orthopedic surgeon were documented as injuries in this study. Musculoskeletal overuse injuries were classified based on the orchard injury classification system. Incidence proportion and risk ratio (RR) and 95% confidence intervals (CIs) for initial injury and injuries requiring surgery were calculated. RESULTS: A total of 261 pitchers (age: 14.2 ± 2.6 years; follow-up: 4.2 ± 2.7 years) were enrolled. Twenty percent of the cohort was followed for ≥7 years. The overall injury incidence was 25.6/100 athletes (95% CI 21-31) with a cumulative surgical incidence of 5.4/100 athletes (95% CI 3.2-8.8). The risk of experiencing shoulder injury (n = 25) and elbow injury (n = 38) were similar (n = 38) (RR 0.7, 95% CI 0.4-1.1). The athletes also presented with a similar frequency of requiring surgery regardless of the injured body part. However, the risk of surgery in those playing beyond the high school level was 4.3 times greater (95% CI 1.2-15.0) than those only playing high school. CONCLUSION: This is the first study to follow a large cohort of youth baseball players as they progress, showing a relatively high arm injury incidence. Shoulder and elbow injury incidence was similar but surgical risk increased playing beyond high school, specifically for the elbow. The high injury frequency and burden of care required by young baseball players as reported in this study is concerning, and strategies to reduce injury should be investigated.

Outcomes After Medial Ulnar Collateral Ligament Graft Repair in Professional Baseball Pitchers With Minimum 2-Year Follow-up.

Background: Rerupture of the reconstructed ulnar collateral ligament (UCL) is becoming more frequent at the professional level of baseball. However, there is no literature describing outcomes after UCL graft repair. Purpose: To evaluate rerupture rate, return to play, performance upon return, and patient-reported outcomes after a novel UCL graft repair technique. Study Design: Case series; Level of evidence, 4. Methods: All included patients underwent UCL graft repair after a previous UCL reconstruction, pitched in at least 1 professional baseball game before repair, and were at least 2 years postprocedure within the same 10-year time period. The authors evaluated patient characteristics and performance metrics, including wins, losses, win percentage, earned run average, innings pitched, walks and hits per inning pitched, for the 2 seasons before and after the procedure. Patients were contacted to assess UCL rerupture, timing of return to sport, current level of competition, Conway score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score. Results: Six players met the inclusion criteria. All had proximal UCL graft ruptures and underwent flexor-pronator tendon repair in combination with graft repair. At a mean (±SD) follow-up of 56.7 ± 37.8 months, no reruptures were encountered, and the mean KJOC score was 87.9 ± 14.6. Of the 6 pitchers who underwent UCL graft repair, 4 (67%) returned to professional pitching at a mean of 17 ± 6 months. Three of the 6 (50%) achieved an excellent Conway score, signifying a return to prior level of sport. There was no significant difference in demographic or preoperative pitching performance metrics between players who did and did not return to pitching. For those players who returned to professional pitching, there was no significant difference between preprocedure and postprocedure performance statistics. Conclusion: Repair of the UCL graft appears to yield comparable rates of return to play and performance with revision UCL reconstruction. This technique serves as a viable alternative for proximal avulsion ruptures of the UCL graft.

Correlation of Rehabilitation and Throwing Program Milestones With Outcomes After Ulnar Collateral Ligament Reconstruction: An Analysis of 717 Professional Baseball Pitchers.

BACKGROUND: There remains room for improvement in surgical outcomes after medial ulnar collateral ligament reconstruction (MUCLR) in professional pitchers. The role and influence of postoperative rehabilitation on the outcomes of MUCLR are unknown. There is a paucity of clinical data in the current literature comparing the success of various postsurgical rehabilitation protocols after MUCLR. PURPOSE: To summarize the current rehabilitation process for professional pitchers recovering from MUCLR, evaluates what player and surgical factors correlate with outcomes, and determines whether rehabilitation timing and milestones correlate with successful outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: 717 professional baseball pitchers who underwent MUCLR between 2010 and 2016 were identified and included in the analysis. Player characteristics evaluated included age at the time of surgery, throwing side dominance, primary pitching role (starter vs reliever), and level of play (MLB, AAA, AA, A). Surgical factors studied included date of surgery, graft type (palmaris longus autograft vs gracilis autograft), and surgical technique (figure of 8 vs docking vs other). The rehabilitation and throwing progression details were as follows: initiation date; first throw date; dates to start throwing from various distances; longest distance thrown; first flat ground throw date; first mound throw date; and first live batting practice (BP) date. The primary outcomes of interest were the ability to return to play at any level (RTP), the ability to return to the same level (RSL), and the time to RTP/RSL. RESULTS: On average, pitchers threw a baseball for the first time 4.9 months after surgery, with a broad range (2.8-14.9 months). For the 675 (94%) pitchers who were able to progress to mound throwing, the first throws off a mound occurred at a mean of 9.4 months after surgery. Before progressing to the mound, the mean longest long-toss distance reached was 137.5 feet, with a broad range (105-300 feet). A high variation in the time to RTP (7.6-53.9 months) and RSL (8.6-60.7 months) was noted. A total of 599 (84%) pitchers were able to RTP at a mean time of 14.9 ± 4.9 months after surgery (range, 7.6-53.9 months). Also, 528 (74%) pitchers were able to RSL after MUCLR at a mean of 17.4 ± 7 months (range, 8.6-60.7 months) postoperatively. Age was the most significant predictor of RTP (hazard ratio [HR], 1.03 [95% CI, 1.01-1.05]; P = .01) and RSL (HR, 0.96 [95% CI, 0.93-0.99]; P < .01). For every 1-year increase in age, there was a 3% increase in the chance of RTP. Conversely, for every 1-year decrease in age, there was a 4% increase in the chance of RSL. MLB players were more likely to RTP (HR, 1.39 [95% CI, 1.18-1.63]; P < .01) but not necessarily to RSL (HR, 0.90 [95% CI, 0.75-1.08]; P = .24). The time from surgery to any of the rehabilitation milestones of interest (first throw, first flat ground pitching, first mound throwing, and first live BP) did not correlate with RTP or RSL (all, P >.05). The same was true for the greatest long-toss distance thrown before transitioning to the mound. CONCLUSION: Significant variability in the postoperative rehabilitation protocols after MUCLR was observed in 717 professional baseball pitchers. The timing of achievement of throwing progression and rehabilitation milestones postoperatively varied widely but did not correlate with outcomes. Player characteristics-except for player age and professional pitching level-did not correlate with RTP and RSL outcomes. Older pitchers and MLB pitchers were more likely to RTP, but younger players were more likely to RSL. Surgical factors did not correlate with rehabilitation outcomes.

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.

No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis.

BACKGROUND: The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT). PURPOSE/HYPOTHESIS: This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects. RESULTS: There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures. CONCLUSION: The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.

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-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.

Establishing the Role of Elbow Muscles by Evaluating Muscle Activation and Co-contraction Levels at Maximal External Rotation in Fastball Pitching.

Background: Baseball pitching is associated with a high prevalence of ulnar collateral ligament injuries, potentially due to the high external valgus load on the medial side of the elbow at the instant of maximal shoulder external rotation (MER). In-vitro studies show that external valgus torque is resisted by the ulnar collateral ligament but could also be compensated by elbow muscles. As the potential active contribution of these muscles in counteracting external valgus load during baseball pitching is unknown, the aim of this study is to determine whether and to what extent the elbow muscles are active at and around MER during a fastball pitch in baseball. Methods: Eleven uninjured pitchers threw 15 fastball pitches. Surface electromyography of six muscles crossing the elbow were measured at 2000 Hz. Electromyography signals were normalized to maximal activity values. Co-contraction index (CCI) was calculated between two pairs of the flexor and extensor elbow muscles. Confidence intervals were calculated at the instant of MER. Four ranges of muscle activity were considered; 0-20% was considered low; 21-40% moderate; 41-60% high and over 60% as very high. To determine MER, the pitching motion was captured with a highspeed camera at 240 Hz. Results: The flexor pronator mass, pronator teres, triceps brachii, biceps brachii, extensor supinator mass and anconeus show moderate activity at MER. Considerable variation between participants was found in all muscles. The CCI revealed co-contraction of the two flexor-extensor muscle pairs at MER. Interpretation: The muscle activation of the flexor and pronator muscles at MER indicates a direct contribution of forearm muscles crossing the medial side of the elbow in counteracting the external valgus load during fastball pitching. The activation of both flexor and extensor muscles indicates an in-direct contributory effect as the combined activity of these muscles counteract opening of the humeroulnar joint space. We believe that active muscular contributions counteracting the elbow valgus torque can be presumed to relieve the ulnar collateral ligament from maximal stress and are thus of importance in injury risk assessment in fastball pitching in baseball.

Early Complications of Ulnar Collateral Ligament Repair With Collagen-Coated Suture Tape Augmentation.

BACKGROUND: Recent innovative techniques have led to renewed interest in ulnar collateral ligament (UCL) repair. Although early outcome data regarding the clinical outcome of overhead athletes undergoing UCL repair with augmentation have been encouraging, long-term data are still needed to evaluate both the appropriate indications and success rate for this procedure. PURPOSE: To describe and evaluate the acute complications seen in a large cohort of patients who underwent UCL repair with internal brace augmentation at a single institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We performed a retrospective chart review of a prospectively collected database, consisting of all patients who underwent UCL repair with internal brace augmentation utilizing a collagen-dipped FiberTape at our institution from August 2013 to January 2020. Patient characteristics, injury setting, side of surgery, and concomitant ulnar nerve transposition procedures were recorded. Early complications of UCL repair (within 6 months of the procedure) were evaluated and characterized as either minor or major, depending on whether the patient required a return to the operating room. RESULTS: Of the 353 patients who underwent UCL repair at our institution with a minimum of 6-month follow-up, 84.7% (299/353) reported no complications, 11.9% (42/353) reported minor complications-including ulnar nerve paresthesia, postoperative medial elbow pain, and postoperative superficial wound complications-and 3.4% (12/353) required a return to the operating room because of a major complication requiring ulnar nerve exploration/debridement, primary ulnar nerve transposition, or heterotopic ossification excision. CONCLUSION: The low major complication rate identified in this study further validates the efficacy of the UCL repair with the internal bracing augmentation technique. Longer term follow-up data are needed to more adequately assess the outcomes and durability of this procedure.

Short-Term Trends in Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players: An Analysis of 25,587 Player-Years.

BACKGROUND: Trends over time in the incidence of ulnar collateral ligament (UCL) surgeries in National Collegiate Athletic Association Division I baseball players are currently unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the trends in UCL surgeries over 3 years in Division I baseball programs. We hypothesized that surgical injuries would be consistently high over the course of the study. STUDY DESIGN: Descriptive epidemiology study. METHODS: Athletic trainers from Division I baseball programs were invited to participate in an electronic survey over 3 seasons. A total of 155 baseball programs agreed to participate in 2017, 294 programs participated in 2018, and 296 programs participated in 2019. After each of the 3 collegiate baseball seasons, the athletic trainer from each program entered anonymous, detailed descriptive data and surgical information on injured players into a secured database. RESULTS: During the 3 years of this study, 100% of the enrolled programs successfully completed the survey (155/155 in year 1, 294/294 in year 2, and 296/296 in year 3). This registry of 745 completed surveys over 3 years represented 25,587 player-years from Division I collegiate baseball. The percentage of programs with at least 1 UCL surgery during this time was 57% in 2017, 51% in 2018, and 49% in 2019. The majority of these players were pitchers (84% overall from the 3 years). Seniors underwent a significantly lower percentage of the UCL surgeries (8% in 2017, 10% in 2018, and 13% in 2019) than did underclassmen. Surgeries were performed most often in-season and least often during the preseason. A slight majority of players undergoing surgery originated from warm-weather states, but the number of these players was never significantly higher than was the number of players from cold-weather states. Most surgeries performed each year were UCL reconstruction, but the percentage of UCL repair with ligament augmentation increased each year (10% UCL repairs in 2017, 20% in 2018, and 25% in 2019). CONCLUSION: UCL injuries requiring surgery were found to be a major source of morbidity in Division I collegiate baseball, supporting our hypothesis. This study can serve as a baseline for tracking long-term trends in UCL surgeries in collegiate baseball.

Pitch break and performance metrics remain unchanged in pitchers who returned to the same level of play after ulnar collateral ligament reconstruction in Major League Baseball pitchers.

BACKGROUND: The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR. MATERIALS AND METHODS: This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown. RESULTS: In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics. CONCLUSION: Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

The ulnar collateral ligament loading paradox between in-vitro and in-vivo studies on baseball pitching (narrative review).

Ulnar collateral ligament (UCL) weakening or tears occur in 16% of professional baseball pitchers. To prevent players from sustaining a UCL injury, it is important to understand the relationship between the UCL properties and elbow stabilizers with the load on the UCL during pitching. In-vitro studies showed that the ultimate external valgus torque of 34 Nm would rupture the UCL, which is in apparent conflict with the reported peak valgus torques in pitching (40-120 Nm). Assuming both observations are correct, the question rises why 'only' 16 out of 100 professional pitchers sustain a UCL rupture. Underestimation of the effect of other structures in in-vivo studies is most likely the explanation of this mismatch because the calculated in-vivo torque also includes possible contributions of functional and structural stabilizers. In-vitro studies show that the flexor-pronator mass has the potential to counteract valgus torque directly, whereas the elbow flexor-extensor muscles combined with the humeroradial joint might have an indirect effect on valgus torque by increasing the joint compression force. Accurate experimental electromyography data and a more detailed (musculoskeletal)mechanical model of the elbow are needed to investigate if and to what extent the structural and functional stabilizers can shield the UCL during pitching.

Return to Performance After Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers: A Case-Control Assessment of Advanced Analytics, Velocity, Spin Rates, and Pitch Movement.

BACKGROUND: There are limited data on the performance or pitching metrics of Major League Baseball (MLB) pitchers who returned to play after ulnar collateral ligament reconstruction (UCLR). PURPOSE: To describe MLB pitcher performance after return from primary UCLR, compare the velocity and pitch characteristics against the preoperative season, and determine if performance analytics can predict successful return to pitching after UCLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This study included 63 pitchers who underwent primary UCLR between 2015 and 2019. Publicly available advanced analytics and pitch metrics from the first 2 postoperative seasons were compared with the preoperative (index) season as well as with an uninjured control group. RESULTS: Overall, 57% of the pitchers successfully returned to the MLB level. Although they threw significantly fewer pitches (P = .012) and innings (P = .022) in postoperative year 1 as compared with the index season, there were no significant differences in pitch velocity, release extension, perceived velocity, or performance as measured by advanced analytics. Also, as compared with the index season, returners demonstrated increased postoperative spin rates on curveballs (P = .001) and sliders (P = .010), and curveball horizontal movement was significantly increased (P = .007); however, horizontal movement was significantly decreased for 4-seam fastballs (P = .026), changeups (P = .005), and sinkers (P = .019). The vertical movement on 4-seam fastballs was greater (P < .001) in postoperative year 1, and the vertical movement on curveballs (P = .031) and sinkers (P = .010) was greater in postoperative year 2 when compared with the index season. Pitchers who failed to return to the MLB level had a lower preoperative strikeout percentage (P = .047), fewer strikeouts per 9 innings pitched (P = .046), fewer wins above replacement ([WAR]; P = .026), and lower player value (P = .030) than the pitchers who returned. CONCLUSION: Pitchers returning to the MLB level after UCLR demonstrated changes in pitch movement profiles and spin rates postoperatively, but there were no differences in velocity or many advanced analytics upon return. Pitchers with lower strikeout metrics, fewer WAR, and less player value before surgery may have an elevated risk of failing to return to the MLB level.

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.

Modified Jobe Versus Docking Technique for Elbow Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes.

BACKGROUND: The modified Jobe and docking techniques are the most common techniques used for elbow ulnar collateral ligament (UCL) reconstruction. Previous systematic reviews have suggested that the docking technique results in superior outcomes as compared with the Jobe (figure-of-8) technique. However, these included results from earlier studies in which the flexor-pronator mass (FPM) was detached and an obligatory submuscular ulnar nerve transposition was performed. PURPOSE/HYPOTHESIS: The purpose was to compare the outcomes and return-to-play (RTP) time between the docking and figure-of-8 techniques for UCL reconstruction. We hypothesized that there would be no significant difference in the proportion of excellent outcomes between techniques when the FPM was preserved and no obligatory submuscular ulnar nerve transposition was performed. We also hypothesized that there would be no significant difference in RTP time between techniques. STUDY DESIGN: Systematic review and meta-analysis. METHODS: This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the primary analysis, techniques were compared in random effects models by using the restricted maximum likelihood method, with weighted effect sizes calculated as the Freeman-Tukey double-arcsine transformed proportion of excellent outcomes for variance stabilization and with summary effects estimated from the inverse double-arcsine transformation per the harmonic mean of the sample sizes. Mean RTP times for techniques were compared in a separate model. RESULTS: There were 21 eligible articles identified, with results for 1842 UCL reconstructions (n = 320, docking; n = 1466, figure-of-8). Without controlling for the effects of flexor-pronator detachment and submuscular ulnar nerve transposition, a significantly larger proportion of excellent outcomes was observed with docking reconstruction (86.58%; 95% CI, 80.42%-91.85%) than with figure-of-8 reconstruction (76.76%; 95% CI, 69.65%-83.25%; P = .031); however, there was no significant difference between techniques when controlling for FPM preservation or detachment with submuscular nerve transposition (P = .139). There was no significant difference between techniques in time to return to sports (P = .729), although no reconstructions with FPM detachment and submuscular ulnar nerve transposition were available for RTP time analysis. CONCLUSION: There was no significant difference in the proportion of excellent Conway Scale outcomes or RTP time between the docking and modified Jobe techniques for UCL reconstruction when the FPM was preserved and routine submuscular ulnar nerve transposition was not performed.