Clinical outcomes after primary repair for thumb ulnar collateral ligament ruptures: a systematic review and meta-analysis.

There is no consensus on the best surgical technique for treating thumb ulnar collateral ligament (UCL) ruptures. This systematic review and meta-analysis investigates which primary repair technique and postoperative immobilization protocol result in the best clinical outcomes. A literature search was conducted in Embase, Medline ALL Ovid, Web of Science Core Selection and Cochrane Central Register of Controlled Trials. Pain, stability, tip pinch strength, key pinch strength, grip strength, return to work and metacarpophalangeal joint range of motion were collected as postoperative outcomes. In total, 29 studies were included. All surgical techniques resulted in satisfactory clinical outcomes, with no significant differences between bone anchor reinsertion, suture fixation, K-wire fixation and a combination of techniques. K-wire immobilization resulted in worse postoperative pain, but similar stability compared to immobilization without a K-wire. Clinical outcomes after thumb UCL repair are excellent, with no differences in clinical outcomes noted among surgical techniques.

Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

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.

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.

Ulnar Collateral Ligament Repair With Suture Tape Augmentation: Can You Overtighten?

BACKGROUND: There has been a renewed interest and, recently, wider implementation of ulnar collateral ligament (UCL) repair in throwing athletes because of improvement in ligament repair technology and corresponding outcome data. PURPOSE: To compare the biomechanical parameters and failure mode between 2 brace-tightening techniques for UCL repair. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven matched pairs of cadaveric arms were procured. One limb from each pair underwent UCL repair with suture tape augmentation with either (1) attempted restoration of physiologic ligament tension or (2) maximal tension. Each specimen was subjected to 10 cycles of subfailure valgus torque at 90º of flexion in the intact state after UCL avulsion and then after UCL repair. Specimens were then torqued to failure. Articular contact mechanics, linear gap distance, angular displacement, failure torque, failure stiffness, and suture tape pull-through length were recorded. Two-way analysis of variance and paired t tests were used to test for statistical differences. RESULTS: There was a significant effect (P = .01) of tightening on joint contact area. There was a significant decrease in gap distance (P = .03) and angular displacement (P = .004) from the torn condition to the repaired condition for the maximum tension group, without a significant difference in gap distance from the intact condition. Failure torque and stiffness were not significantly different between groups, although there was a significant difference (P = .001) in the overall suture tape pull-through length. CONCLUSION: Although there are potential physiologic changes at time zero-including significant decreases in contact area, normalized gap distance, and normalized angular displacement with maximal tension repair-examination of failure biomechanics suggests that these effects may be mitigated over time within the construct by suture tape pull-through at the tape-anchor interface. Neither method of UCL repair with suture tape augmentation resulted in overconstraint of the elbow joint compared with the native ligament biomechanics. CLINICAL RELEVANCE: As more long-term outcome data from UCL repair with suture tape augmentation emerge, there will be wider implementation with various techniques to tension the suture tape. Examining the potential biomechanical sequelae of the UCL repair construct applied under maximal tension will help further refine recommendations for surgeons who utilize this technique for UCL repair.

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.

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.

The posterolateral ligament of the elbow: anatomy and clinical relevance.

BACKGROUND: The posterolateral capsule was recognized in the past as an important structure for elbow stability but was later disregarded. Two recent biomechanical studies demonstrated its role in preventing posterolateral instability, and thus it should be identified as a distinct ligament: the posterolateral ligament (PLL). This study includes 2 parts: an anatomic study of the PLL's footprint and a collection of 5 cases of pathologic lesions of the PLL. METHODS: Six cadaveric upper limbs were assessed. The attachments of the PLL were dissected, the footprints were marked and photographed, and the 2-dimensional area and length were measured. RESULTS: The mean proximal attachment dimensions were a length of 13 mm and an area of 101 mm2, and the mean distal attachment dimensions were 19 mm and 111 mm2, respectively. There were 2 cases of posterolateral elbow pain in professional cricket bowlers, diagnosed radiographically as enthesopathy of the PLL's proximal attachment on the posterior capitellum, probably due to repeated forced hyperextension of the elbow. Both patients were treated by débridement of the posterior capitellum and reattachment of the PLL, with complete resolution of symptoms. In addition, there were 3 cases of clinical posterolateral rotatory instability in young patients. Two athletes had an isolated acute tear of the PLL, and on physical examination, both had positive posterior draw test results but negative pivot-shift test results. Both underwent elbow arthroscopy and repair of the PLL with resolution of symptoms. The third patient had long-standing recurrent elbow instability, following a failed lateral ulnar collateral ligament reconstruction, in the presence of an Osborne-Cotterill lesion. He underwent revision lateral ulnar collateral ligament reconstruction, bone grafting of the bony lesion, and reattachment of the PLL, with complete resolution of symptomatic posterolateral rotatory instability. CONCLUSIONS: The PLL of the elbow has a significant role in the elbow's posterolateral stability. Its footprints were described, and its clinical significance was demonstrated in cases of elbow instability caused by acute ligament tears and elbow pain due to ligament enthesopathy. Surgeons should be aware of this structure and potential pathology related to its injury.

Elbow Ulnar Collateral Ligament Tears in 2023: Evaluation and Management.

The ulnar collateral ligament, also called the medial collateral ligament of the elbow, is the primary stabilizer against valgus loads. This ligament can be traumatically torn, such as in an elbow dislocation, or can tear through attritional damage with overhead sports. Although baseball pitching is the most common contributor, these injuries also occur with volleyball, gymnastics, and javelin throwing. Patients most commonly report a history of medial elbow pain with associated loss of command, control, and throw velocity. The ulnar nerve lies directly superficial to the posterior band of the ulnar collateral ligament and ulnar neuritis is commonly associated with ulnar collateral ligament pathology. Nonsurgical treatment, including rest from activity, flexor-pronator strengthening, and possible platelet-rich plasma injections, can be considered for partial-thickness tears. Surgical treatment can be considered for patients in whom nonsurgical treatment fails and full-thickness tears. Historically, surgical treatment involved reconstruction of the ligament with a tendon graft. Ipsilateral palmaris longus autograft has been the most commonly used graft, but contralateral palmaris, autograft hamstring tendons, and allograft tendon have also been used. This procedure has a high rate of return to play and a low complication rate, but most athletes require 12 to 18 months to fully return. More recently, repair of the ligament, with the addition of a biologic ingrowth ligament augmentation suture, has demonstrated similarly high rates of return to play and low complication rates, with a full return to play in 6 months.

Traumatic Hallux Metatarsophalangeal Joint Medial Collateral Ligament Avulsion in a Professional Surfer: Suture Anchor Repair and Suture Tape Augmentation: A Case Report.

CASE: Acute medial collateral ligament (MCL) tears of the great toe metatarsophalangeal joint are rare, leading to sparse literature regarding their management. Suture anchor repair with suture tape augmentation is an effective treatment of thumb ulnar collateral ligament tears, a close analog. This case report presents a 23-year-old professional surfer with an acute hallux MCL avulsion. Management included repair with suture anchor and suture tape augmentation. The patient returned to sport quickly and had no pain or complications at 1-year follow-up. CONCLUSION: In this case of acute MCL tear of the great toe, suture anchor repair with suture tape augmentation facilitated early mobilization, rapid rehabilitation, return to competitive sport, and sustained good outcome. LEVEL OF EVIDENCE: Level V.

Implant-free anatomical reconstruction of thumb metacarpophalangeal joint chronic ulnar collateral ligament injuries.

A technique is described to treat chronic instability of the metacarpophalangeal joint of the thumb caused by rupture of the ulnar collateral ligament using a palmaris longus tendon graft without implants. Good results were obtained in eight patients.

[Return to throwing sports after upper extremity injury and overuse : A criteria-based approach using an ulnar collateral ligament injury as an example]. / Zurück zum Wurfsport nach Verletzung und Überlastung an der oberen Extremität : Ein kriterienbasierter Ansatz am Beispiel einer Verletzung des Ligamentum collaterale ulnare.

BACKGROUND: Uniform procedures for rehabilitation and follow-up treatment after injuries and surgeries at the upper extremity do not exist. Accordingly, only a few approaches for the follow-up treatment of instabilities of the elbow joint have been described. OBJECTIVES: The authors show how rehabilitation before sport-specific training after rupture of the ulnar collateral ligament in a female handball player was objectivized and controlled using the results of functional tests. MATERIALS AND METHODS: The follow-up treatment of a semi-professional female handball player (aged 20) after rupture of the ulnar collateral ligament was objectivized and controlled using the return to activity algorithm. In addition to the comparisons with the values of the unaffected side, comparative results of 14 uninjured female handball players were used for guidance. RESULTS/CONCLUSIONS: The patient was able to participate fully in sport-specific training after 15 weeks and participate in her first competitive match after 20 weeks. On the affected side, she achieved a distance of 118% of her upper limb length on the medial reach of the upper quarter Y balance test and 63 valid contacts on the wall hop test. The values achieved at the end of rehabilitation were higher than the average values of the control group.

Thumb metacarpophalangeal joint morphology and reconstruction of the ruptured ulnar collateral ligament.

Studies on graft reconstruction techniques for ruptured thumb metacarpophalangeal (MCP) ulnar collateral ligaments (UCL) do not consider the variety of MCP joint morphology. Optimal reconstruction method for flat MCP joints is therefore unclear. Twenty-four fresh-frozen, human thumbs were tested for flexion, extension and valgus stability of the MCP joint. After resection of the UCL, four reconstruction methods, differing in the metacarpal origin and phalangeal attachment, were performed on each specimen, which were then tested again in the same way. Specimens were grouped as 'round' or 'flat' depending on morphometric parameters and group differences were analysed. In flat joints, only the non-anatomical Glickel reconstruction and a modified Fairhurst reconstruction maintained normal mobility and stability. In round joints, only the Glickel reconstruction maintained normal mobility and stability. The original Fairhurst method and a modification with the origin palmar in the metacarpus were disadvantageous in both flat and round joints.

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.

Biomechanical Stability of Lateral Ulnar Collateral Ligament Reconstruction and Repair of the Elbow: The Role of Ligament Bracing on Gap Formation and Stabilization.

BACKGROUND: Augmented (internal braced) lateral ulnar collateral ligament (LUCL) repair has been biomechanically compared with reconstruction techniques in the elbow. However, LUCL repair alone has not yet been compared with augmented repair and reconstruction techniques. HYPOTHESIS: Internal bracing of LUCL repair would improve time-zero stabilization regarding gap formation, stiffness, and residual torque as compared with repair alone and reconstruction techniques to restore native elbow stability. STUDY DESIGN: Controlled laboratory study. METHODS: Overall, 24 cadaveric elbows were used for either internal braced LUCL repair (Repair-IB) or single- and double-strand ligament reconstruction with triceps (Recon-TR) and palmaris longus tendon graft (Recon-PL), respectively. Laxity testing in external rotation was consecutively performed at 90° of elbow flexion on the intact, dissected, and repaired conditions and with the previously assigned techniques. First, intact elbows were loaded to 7.0-N·m external torque to evaluate time-zero ligament rotations at 2.5, 4.0, 5.5, and 7.0 N·m. Rotation-controlled cycling was performed (total of 1000 cycles) for each surgical condition. Gapping, stiffness, and residual torque were analyzed. Finally, these and 8 additional intact elbows underwent torque-to-failure testing (30 deg/min). RESULTS: The dissected state showed the highest gap formation and lowest peak torques (P < .001). While gap formation of Repair-IB (P < .021) was significantly lower than that of repair without internal bracing at all rotation levels, gaps of Recon-PL were similar to and Recon-TR were significantly higher than those of Repair-IB except for the highest torsion level. Residual peak torques at specific rotation angles between native state and Recon-TR (α2.5), Recon-PL (α4.0), and Repair-IB (α5.5) were similar; all other comparisons were significantly different (P < .027). Torsional stiffness of Repair-IB was significantly higher at all rotation angles measured. Analysis of covariance showed significantly less gap formation over residual peak torques for Repair-IB (P < .001) as compared with all other groups. The native state failure load was significantly higher than Recon-PL and Recon-TR failure loads, with similar stiffness to all other groups. CONCLUSION: Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. Recon-TR demonstrated lower residual peak torques but provided near-native rotational stiffness. CLINICAL RELEVANCE: Internal bracing of LUCL repair may reduce suture-tearing effects through tissue and provide sufficient stabilization for healing throughout accelerated and reliable recovery without the need for a tendon graft.

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.

Clinical and functional outcomes of surgical treatment of grade III ulnar collateral ligament injuries of thumb metacarpophalangeal joint.

OBJECTIVES: The aim of this study was to compare the clinical and functional outcomes of three surgical techniques (subperiosteal suture, bone anchor and direct repair) for the management of severe acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with a minimum of 1 year follow-up. MATERIAL AND METHODS: Between 2015 and 2020, 230 collateral ligament injuries required surgical treatment in our department. After the inclusion and exclusion criteria were applied, 100 were included in the study. The Glickel score and functional scores such as QuickDASH and PRWE were assessed. Time to return to work and to sport was quantified. RESULTS: Ulnar collateral ligament injuries affected men who were statistically younger than women (41.8 years old vs 48.3). Subperiosteal suture was the preferred technique (81%), then bone anchor reattachment (12%) and direct repair (7%). All three techniques produced excellent stability (91-100%). Better range of motion was reported in the subperiosteal group, but better strength was found in the bone anchor group. Subperiosteal suture had 89% excellent and good results, while there was 83% in the bone anchor group and 71% in the direct repair group. Mean time to return to work was 2 months in the bone anchor group versus 3 months in the subperiosteal group. Mean QuickDASH was 8.7/100 and mean PRWE was 7.1/100. CONCLUSION: This is the biggest case series to date on surgical treatment of severe ulnar collateral ligament injuries of the thumb metacarpophalangeal joint. The subperiosteal technique is simpler and less expensive. While the results are not often described in the literature, it produces comparable clinical and functional outcomes to bone anchor reattachment with a minimum follow-up of 1 year.

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.

Can we do it faster? accelerated rehabilitation following thumb ulnar collateral ligament repair with suture tape augmentation.

Ulnar Collateral Ligament (UCL) injuries are the most common thumb metacarpophalangeal joint ligamentinjury. Rehabilitation protocols traditionally permit return to sport at 12 weeks post-surgery. In this article, we propose anacellerated rehabilitation protocol permitting return to sport at 5-6 post-surgery in the recreational athlete.

Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods.

PURPOSE: Differences in range of motion, pinch strength, biomechanical strength, or joint angulation have previously been investigated for various means of treatment of ulnar collateral ligament (UCL) tears. We sought to address a gap in the literature by comparing thumb metacarpophalangeal (MCP) joint angle measurements and biomechanical strength before complete, acute UCL tear and after repair with suture anchors (SA), suture tape (ST) anchor augmentation, or reconstruction with palmaris longus graft (PL). METHODS: Thumbs and, if present, the PL tendon were harvested from 15 fresh-frozen cadavers. Each thumb specimen was secured into a servohydraulic biomechanical testing frame to evaluate native radiographic MCP joint angles at 0° flexion when loaded with 0, 5, and 13 N of radial force. Subsequently, a single hand surgeon (S.M.K.) performed complete transection and UCL repair via 1 of 3 methods: SA (n = 5), ST (n = 5), or reconstruction with PL (n = 5). Following repair, MCP joint angles were radiographically evaluated. Specimens that did not fail during joint angle testing were transferred to a separate testing frame for load-to-failure testing. Angle measurements and mean load-to-failure were compared between the groups, and angulation was also compared with each group's native control. RESULTS: Both ST and SA groups demonstrated comparable stiffness to their native controls, whereas the PL group was significantly more lax. The ST repair was significantly stiffer than the other constructs. ST also required higher forces to reach failure compared to both SA and PL. No difference was found between SA and PL groups. CONCLUSIONS: Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure. CLINICAL RELEVANCE: For complete, acute tears of the thumb UCL, ST may be superior for maintaining MCP joint stability and strength over SA and PL.