Characterizing focal muscle signal on MRI in flexor-pronator muscles' status post ulnar collateral ligament reconstruction.

OBJECTIVE: Focal high signal is commonly seen about the flexor pronator mass on MRI in some patients after ulnar collateral ligament (UCL) reconstruction of the elbow. The etiology of this high signal is unclear and not described in literature. The hypothesis is that the edema we see on post-operative MRI is related to palmaris longus graft harvest rather than secondary to other causes of muscle edema such as denervation or muscle strain. METHODS AND MATERIALS: An IRB waiver-approved, retrospective search of our radiology database was conducted using the keywords "ucl," "elbow," and "reconstruction" between 1/01/2012 and 1/01/2022, with search parameters set as MRI for exam type. The images were reviewed to evaluate for high signal at the flexor pronator mass by a junior and a senior musculoskeletal radiologist. The surgical notes were then reviewed in electronic medical record system to see which graft was used for the UCL reconstruction. RESULTS: The cohort comprised of 33 patients (1 female/32males, 14-51 years old) who had undergone UCL reconstructions. Four patients were excluded from the study secondary to the surgical note not specifying which graft was used. The surgical and imaging dates were also recorded with the largest time gap of 7 years between the surgery and imaging. Seventeen of the 29 patients had palmaris longus harvested from the ipsilateral arm, 1 patient had palmaris longus harvested from the contralateral arm, 2 patients had an internal brace, and 9 patients had a hamstring graft. Seventeen out of 17 (100%) patients with ipsilateral palmaris longus graft demonstrated focal edema at the flexor pronator mass while 0/12 of the patients without the palmaris longus graft showed the focal edema seen by its counterparts. CONCLUSION: High signal which is commonly seen at the flexor pronator mass in patient status most UCL reconstruction of the elbow is secondary to the palmaris longus harvest rather than other etiologies such as muscle strain, retear, or trauma.

Editorial Commentary: The Difficulties of Assessing Return to Play and Return to Performance After Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament (UCL) tears have moved from a career-ending injury to one in which success is almost expected from reconstruction. In reality, however, success from a UCL reconstruction is not guaranteed. As we have attempted to assess the true success rate of UCL reconstructions, we have also learned the difficulties of this assessment. Rates of return to sport after UCL reconstruction vary by level of play, the primary or revision status of the repair, along with the specific surgical techniques performed, the chronicity of the tear, the rehabilitation protocols associated with the surgery, and more. Return to sport is difficult to assess, as high school, collegiate, and even professional careers can be variable and there are no standard definitions of "returning to play." These variables also affect our assessments of performance after UCL reconstruction. Decisions for UCL reconstructions and appropriate counseling of patients regarding the likelihood of success currently remain an individual process.

Editorial Commentary: Ulnar Collateral Ligament Repair With Suture Augmentation May Be Superior to Reconstruction for Proximal or Distal Tears With Good- Quality Tissue.

Ulnar collateral ligament (UCL) tears in the elbow have been rising in recent years, most specifically in baseball players. Although many of these tears occur in professional (minor and major league) baseball pitchers, there has been a dramatic rise in UCL injuries in adolescents, at a rate of 9% per year. Although some UCL tears can be treated conservatively, those that fail conservative treatment often require surgical intervention to allow players to return to sport. Although UCL reconstruction has been the gold standard in surgical treatment for many years, UCL repair with suture augmentation has grown in popularity. Initial results of UCL repair with suture augmentation have been promising, and a recent review comparing UCL repair with suture augmentation from both a biomechanical and clinical outcome perspective confirms that UCL repair may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue for repair.

Variable Return to Play and Sport Performance After Elbow Ulnar Collateral Ligament Reconstruction in Baseball Players: A Systematic Review.

PURPOSE: To evaluate return to play (RTP) and return to same level of play (RTSP) rates as well as preoperative and postoperative in-game performance metrics in baseball pitchers who underwent ulnar collateral ligament reconstruction (UCLR). Secondarily, this review sought to assess outcomes based on primary versus revision UCLR as well as level of competition. METHODS: This review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane Database of Systematic Reviews were queried to identify articles evaluating UCLR in baseball players between January 2002 and October 2022. Data included RTP, RTSP, and performance metrics including earned run average, innings pitched, walks and hits per inning pitched, batting average against, strikeouts per 9 innings, walks per 9 innings, percentage of fastballs thrown, and average fastball velocity. The Methodological Index for Non-randomized Studies criteria were used for quality assessment. RESULTS: Analysis included 25 articles reporting on 2,100 elbows. After primary UCLR, RTP ranged from 336 to 615 days (57% to 100% achieved) and RTSP ranged from 330 to 513 days (61% to 95%). After revision UCLR, RTP ranged from 381 to 631 days (67% to 98%) and RTSP ranged from 518 to 575 days (42% to 78%). When stratifying primary UCLR outcomes by competitive level, RTP and RTSP ranged respectively from 417 to 615 days (75% to 100%) and 513 days (73% to 87%) for Major League Baseball only, 409 to 615 days (57% to 100%) and 470 to 513 days (61% to 95%) for Major League Baseball plus Minor League Baseball, and 336 to 516 days (73% to 85%) and 330 days (55% to 74%) for college plus high school. Heterogeneity was seen in postoperative sports performance metrics. CONCLUSIONS: Although more than half of baseball players appear able to RTP after primary and revision UCLR, RTSP rates after revision UCLR were as low as 42% in the literature. Preoperative and postoperative performance metrics varied. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

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

PURPOSE: To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation. METHODS: A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications. RESULTS: In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%). CONCLUSIONS: Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes. CLINICAL RELEVANCE: UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.

Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study.

PURPOSE: The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint. METHODS: Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up. RESULTS: Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications. CONCLUSIONS: Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players.

BACKGROUND AND HYPOTHESIS: A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique. MATERIALS AND METHODS: Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score. RESULTS: Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05). CONCLUSION: RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

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.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow.

BACKGROUND: Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS: Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS: Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS: The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Rehabilitation of the painful elbow.

Although lateral elbow pain and medial ulnar collateral ligament injury are common musculoskeletal pathologies in overhead athletes, the evidence supporting specific interventions for managing these conditions is scarce. Management of these conditions has been guided mostly by expert opinion rather than empirical evidence, yet the lack of comparative data in the literature has not negatively affected return-to-play rates following surgery. However, an understanding of what is known regarding unimodal and multimodal treatments for lateral elbow pain and medial ulnar collateral ligament injury is needed for clinicians to select evidence-based treatment pathways and highlight what is not known to develop future high-quality investigations.

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.

Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement.

PURPOSE: To establish consensus statements on the treatment of ulnar collateral ligament (UCL) injuries and to investigate whether consensus on these distinct topics could be reached. METHODS: A modified consensus technique was conducted among 26 elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90% to 99% agreement. RESULTS: Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. CONCLUSIONS: There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and previous injury. There was unanimous agreement that advanced imaging in the form of either magnetic resonance imaging or magnetic resonance arthroscopy should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of nonoperative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery, and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for return to sport (RTS) were regarding portions of the physical examination should be considered when determining whether to allow a player to RTS; unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. LEVEL OF EVIDENCE: V, expert opinion.

Increased Pitch Velocity Is Associated With Throwing Arm Kinetics, Injury Risk, and Ulnar Collateral Ligament Reconstruction in Adolescent, Collegiate, and Professional Baseball Pitchers: A Qualitative Systematic Review.

PURPOSE: To assess the relationship between pitch velocity and throwing arm kinetics, injury, and ulnar collateral ligament reconstruction (UCLr) among high school, collegiate, and professional baseball pitchers. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), and OVID/MEDLINE (2008-2019) were queried for articles that reported on pitch velocity predicting throwing arm kinetics, injury, or UCLr. The Methodological Index for Non-randomized Studies checklist was used to evaluate the quality of all included studies. Descriptive statistics with ranges were used to quantify data where appropriate. RESULTS: A total of 24 studies examining 2,896 pitchers, with Level of Evidence II-V were included. Intergroup analysis noted pitch velocity was significantly correlated with elbow varus torque in high school (R2 = 0.36), collegiate (R2 = 0.29), and professional (R2 = 0.076) pitchers. Elbow distraction force was positively associated with ball velocity in interpitcher analyses of high school (R2 = 0.373), professional (R2 = 0.175), and mixed-cohort evaluations (R2 = 0.624). Intragroup analysis demonstrated a strong association between pitch velocity and elbow varus torque (R2 = 0.922-0.957) and elbow distraction force (R2 = 0.910) in professional pitchers. Faster ball velocity was positively associated with a history of throwing arm injury (R2 = 0.194) in nonadult pitchers. In 2 studies evaluating professionals, injured pitchers had faster pitch velocity before injury compared with uninjured controls (P = .014; P = .0354). The need for UCLr was positively correlated with pitch velocity (R2 = 0.036) in professional pitchers. The consequences of UCLr noted little to no decrease in pitch velocity. CONCLUSIONS: Professional baseball pitchers with faster pitch velocity may be at the greatest risk of elbow injury and subsequent UCLr, potentially through the mechanism of increased distractive forces on the medial elbow complex. When a pitcher ultimately undergoes UCLr, decreases in pitching performance are unlikely, but may occur, which should encourage pitchers to caution against maximizing pitch velocity. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Outcomes following arthroscopic posteromedial osteophyte resection and risk of future ulnar collateral ligament reconstruction.

BACKGROUND AND HYPOTHESIS: Despite successful return-to-sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of osteophyte removal is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who undergo isolated posteromedial osteophyte resection subsequently require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophytes in overhead athletes and determine whether overhead athletes who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. We hypothesized that there would be a high rate of RTS following osteophyte resection and that players who underwent arthroscopic posteromedial osteophyte resection would have a >10% risk of requiring subsequent UCLR or UCL repair. MATERIALS AND METHODS: All patients who underwent elbow arthroscopy from 2010-2020 at a single institution were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms, and had no history of elbow surgery. Primary outcomes included RTS rate, complications, and subsequent shoulder and/or elbow injury and surgery, as well as several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews elbow score, and Conway-Jobe score). RESULTS: Overall, 36 overhead athletes were evaluated at 5.1 ± 3.4 years postoperatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. Of the overhead athletes, 77% were able to RTS; the mean Kerlan-Jobe Orthopaedic Clinic and satisfaction scores were 70 and 75, respectively; and 89% of athletes had either excellent (73%) or good (16%) Conway-Jobe scores at long-term follow-up. Subsequent UCLR was required in 18% of baseball pitchers (n = 5) at a median of 13 months postoperatively. Of the 5 UCLRs, 3 were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months postoperatively) whereas the other 2 were performed at 6.2 and 7.5 years postoperatively. CONCLUSION: Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic resection of posteromedial osteophytes for posteromedial impingement have an 18% risk of subsequent UCLR.

Inconsistencies in reporting risk factors for ulnar collateral ligament reconstruction failure: a systematic review.

BACKGROUND: When return to sport (RTS) at a competitive level is desired, treatment of injury to the ulnar collateral ligament (UCL) frequently involves surgical reconstruction. Although RTS rates between 66% and 98% have been reported, there remains a paucity of comparative clinical studies, with far fewer reporting statistically significant risk factors for reconstruction failure. The goal of this study was to perform a systematic review of the literature to demonstrate the variety and inconsistency with which risk factors associated with reconstruction failure are reported. MATERIALS AND METHODS: A systematic review of the PubMed Central and MEDLINE databases was performed to identify clinical outcome studies reporting ≥1 statistically significant risk factor associated with failure of UCL reconstruction. Failure was defined as (1) reinjury, recurrent instability, or need for revision surgery; (2) failure show improvement in postoperative patient-reported outcomes (PROs); or (3) failure to RTS at the preinjury level (RSL). RESULTS: A total of 349 unique studies were initially identified, of which 12 were deemed eligible for inclusion in our study. Of these 12 studies, 4 defined outcomes based on recurrent instability, reinjury, or revision surgery; 2 defined outcomes based on PROs; and 6 defined outcomes based on RSL. In the group with instability, reinjury, or revision failure, 11 significant risk factors were identified across all studies: age, height, body mass index, professional experience, injury to the nondominant arm, history of competitive throwing, mechanism of injury, history of a psychiatric diagnosis, presence of preoperative instability or stiffness, postoperative workload, and time to RTS. In the PRO failure group, 12 risk factors were identified across all studies: age, status as a military cadet, injury to the nondominant arm, graft type, baseball position, current injury to the ipsilateral arm, current level of competition attributed to reconstruction surgery, shoulder surgery after reconstruction, no competitive throwing history, non-throwing mechanism of injury, history of a psychiatric diagnosis, and preoperative instability or stiffness. In the RSL failure group, 4 risk factors were identified across all studies: age, ulnar neuritis, level of professional play, and amount of time spent at the professional level. CONCLUSIONS: Age, level of professional play prior to surgery, postoperative workload, and time at the professional level are the most commonly reported risk factors associated with UCL reconstruction failure. There remains a paucity of data associating risk factors with patient-specific outcomes and marked levels of inconsistency and conflict among the studies that report such data.

Lateral ulnar collateral ligament reconstruction using an autologous triceps tendon graft for subclinical posterolateral rotatory instability in recalcitrant lateral epicondylitis.

PURPOSE: To evaluate midterm outcome of lateral ulnar collateral ligament (LUCL) repair with triceps autograft in patients with PLRI under recalcitrant lateral epicondylitis. METHODS: In total, 25 elbows (23 patients) with recalcitrant epicondylitis longer than 12 months were included into this retrospective study. All patients underwent arthroscopic instability examination. In 18 elbows (16 patients, mean age 47.4 years, range 25-60), PLRI was verified, and an LUCL repair using an autologous triceps tendon graft was performed. Clinical outcome was evaluated before and at least 3 years after surgery using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form-Elbow Score (ASES-E), Liverpool Elbow Score (LES), Mayo Elbow Performance Index (MEPI), Patient-Rated Elbow Evaluation score (PREE), Subjective Elbow Value (SEV), quick Disabilities of the Arm, Shoulder, and Hand score (qDASH), and the visual analog scale (VAS) for pain. Postoperative satisfaction with the procedure and complications were recorded. RESULTS: Seventeen patients were available at a mean follow-up of 66.4 months (range 48-81). Patient satisfaction postoperatively was reported in 15 elbows as excellent (90%-100%) and 2 as moderate, with 93.1% overall. All scores of the 3 female and 12 male patients significantly increased from pre- to the postoperative follow-up (ASES: 28.3 ± 10.7 to 54.6 ± 12.1, P < .001; MEPI: 49.2 ± 8.3 to 90.5 ± 15.4, P < .001; PREE: 66.1 ± 14.9 to 11.3 ± 23.5, P < .001; qDASH: 63.2 ± 21.1 to 11.5 ± 22.6, P < .001; VAS: 8.75 ± 1.0 to 1.5 ± 2.0, P < .001). All patients suffered from high extension pain preoperatively, which was reported to be relieved after surgery. No recurrent instability or major complication occurred. CONCLUSION: The repair and augmentation of the LUCL with a triceps tendon autograft reached significant improvements; hence, it seems to be a good treatment option for posterolateral elbow rotatory instability with promising midterm results under a low rate of recurrent instability.

What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction. METHODS: Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries. RESULTS: The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P < .001). Significant indications for repair included distal partial (OR = 1.6, 95% CI 1.0, 2.1, P < .001) and full-thickness tears (OR = 1.7, 95% CI 1.1, 2.3, P < .001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR = 3.0, 95% CI -5.0, -1.0, P = .004). Ultrasound stress testing was requested in 78% of partial tears. CONCLUSIONS: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management.

Ulnar collateral ligament (UCL) injuries of the elbow are common in overhead throwing athletes. With throwing, the elbow experiences substantial valgus stress and repetitive microtrauma can lead to injury. Increasing rates of injury among both youth and professional throwers has resulted in a "UCL epidemic." Ulnar collateral ligament reconstruction ("Tommy John Surgery") became a part of the public consciousness after Tommy John returned to professional baseball after a UCL reconstruction with Dr Frank Jobe for what was once considered a career-ending injury. Partial tears and some athletes with complete UCL injuries can be managed without surgery. Since the introduction of UCL reconstruction, technical modifications have aimed to decrease complications and increase return-to-play rates. Ulnar collateral ligament repair has reemerged as a potential surgical option for some throwers. Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries.

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

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously. METHODS: Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque. RESULTS: Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P = .002). The DDA mean cyclic stiffness was significantly greater than the Native (P < .001), DD (P = .025), and MD (P < .001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51° ± 1.59°) and least for the DDA group (1.01° ± 0.57°) but did not reach statistical significance. CONCLUSION: Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.

Revision ulnar collateral ligament reconstruction in Major League Baseball pitchers: effects of fastball velocity and usage.

BACKGROUND: Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball (FB) velocity and usage (FB%) in this setting. HYPOTHESIS/PURPOSE: The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to postoperative FB velocity and FB% at 1 and 2 years after return to play. The hypothesis was postoperative FB velocity and FB% would significantly decrease vs. prerevision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% in comparison to a matched group of MLB pitchers after primary UCLR. METHODS: Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for 4-seam (4FB) and 2-seam (2FB) fastballs and total FB% for pitchers in the prerevision year as well as the 2 years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison. RESULTS: There were no significant differences in FB velocity between prerevision levels (4FB 92.9 mph, 2FB 91.4 mph) and years 1 (4FB 92.5 mph, 2FB 91.2 mph) and 2 (4FB 93.4 mph, 2FB 91.1 mph) after revision UCLR. FB% decreased from the prerevision season (60.1) and the first (56.2, P = .036) and second years (52.5, P = .002) after return. There were no significant differences between FB velocity and FB% or between the revision and primary UCLR groups. CONCLUSION: Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity to their prerevision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB%, which may suggest less confidence in their FB after RTP.