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Ulnar Collateral Ligament Reconstruction: Where Do We Stand in 2021? Brandon J Ulnar Collateral Ligament Reconstruction: Where Do We Stand In 2021? Brandon J. Erickson, MD Section Chief, Shoulder & Elbow Surgery: Phelps Hospital Assistant Professor, Department of Orthopaedic Surgery Sidney Kimmel Medical College of Thomas Jefferson University Assistant Professor, Department of Orthopaedic Surgery Zucker School of Medicine, Hofstra University Assistant Team Physicians: Philadelphia Phillies Disclosures • AOSSM, AAOS, ASES committee member • Hospitality/education payments: Arthrex, Smith & Nephew, Linvatec, Stryker, DePuy Synthes • Consulting: Arthrex Lineup • Dines: UCL epidemiology, risk factors • Dugas: UCL Repair in 2021: Which patients, technique, RTS and outcomes • Schickendantz: UCLR in 2021: Which patients, technique, RTS and outcomes • Ahmad: Sometimes it's more than the UCL: Concomitant procedures with UCL surgery • Erickson: Discussion and case presentations Meet Our Faculty – Joshua Dines • Undergrad: Dartmouth • Medical School: Cornell • Residency: HSS • Sports Fellowship: KJOC • Current Practice: Hospital for Special Surgery • Topic: UCL Epidemiology and Risk Factors • Team Physician: • New York Mets Meet Our Faculty – Jeffrey Dugas • Undergrad: North Carolina State • Medical School: Duke • Residency: HSS • Sports Fellowship: ASMI • Current Practice: ASMI • Topic: UCL Repair in 2021 • Team Physician (too many to list them all): • Troy Trojans • WWE • USA Cheer Meet Our Faculty – Mark Schickendantz • Undergrad: ??? • Medical School: St. Louis University • Residency: Cleveland Clinic • Sports Fellowship: Steadman Hawkins • Current Practice: Cleveland Clinic • Topic: UCLR in 2021 • Team Physician: • Cleveland Indians Meet Our Faculty – Christopher Ahmad • Undergrad: Columbia • Medical School: ??? • Residency: Columbia • Sports Fellowship: KJOC • Current Practice: Columbia • Topic: Sometimes it's more than the UCL • Team Physician: • New York Yankees • Rockland Boulders Meet The Faculty – Brandon Erickson • Undergrad: Notre Dame • Medical School: Tufts • Residency: Rush • Fellowship: HSS • Current Practice: Rothman • Assistant Team Physician: • Philadelphia Phillies Bringing It Home • UCL injuries are on the rise • UCLR is a good procedure with reliable outcomes • While there are many surgical variables, most of these do not effect outcomes • Players should be cautioned about RTS too quickly following UCLR Objectives • Understand history and physical exam findings that are seen with UCL tears • Understand basic anatomy and function of the UCL • Understand the various treatment options for UCL injuries, and which patients would benefit from which treatment • Understand the rehabilitation process following surgery for UCL tears 2013 • Created a database of all UCLR in MLB players from 1974 until 2013 • 179 MLB Pitchers underwent UCLR • 83% RTS in MLB • 97.2% RTS in MLB or minors • No significant decline in performance upon RTS 2013 Tommy John Surgeries in MLB Pitchers by Year 35 30 25 20 15 10 5 Number of UCLR Performed of UCLR Number 0 1980 1985 1990 1995 2000 2005 2010 2015 Year of Surgery 2015 PearlDiver Database Study from 2007 – 2011 790 patients underwent UCLR 695 males, 95 females Avg annual incidence: 3.96 per 100,000 for the overall population 22 per 100,000 for patients aged 15 to 19 years Overall average annual growth was 4.2%. Incidence of UCLR in 15- to 19-year-olds increased at an average rate of 9.12% per year (P = .009) 2015 P<0.001 Bottom Line…It’s A Problem Our Patient 17 y/o LHD M high school junior Has been a pitcher all his life No prior elbow injuries L medial elbow pain started after a specific pitch Player History: Let’s Define Risk Factors 2011 201 6 • 28 males between 13-16 threw a simulated game • Shoulder ROM was assessed before and after the game • Velocity and accuracy were measured for every pitch, and every 15th pitch was videotaped from 2 views • Quantitative and qualitative mechanics were measured from these videos • Perceived fatigue and pain were assessed after each inning using a visual analog scale 201 6 • The model functioned well: • Pitchers became progressively more fatigued (0.3 → 3.5), had more pain (0.1 →1.6), and pitched with a lower velocity (73 mph → 71 mph) as pitch number increased (all significant) • No upper extremity kinematics changed with fatigue • Knee flexion angle at ball release significantly increased with increasing pitch number (49° → 53°) • Hip to shoulder separation significantly increased with increasing pitch number (90% at pitch 15 to 40% at pitch 90) Erickson, B. J., Sgori, T., Chalmers, P. N., Vignona, P., Lesniak, M., Bush-Joseph, C. A., et al. (2016). The Impact of Fatigue on Baseball Pitching Mechanics in Adolescent Male Pitchers. Arthroscopy • 247 MLB Pitchers Underwent UCLR as of June 1, 2014 • State/country where MLB pitcher played Baseball was used to determine warm vs. cold • Cold states were north of 33rd parallel; warm states were south • Why the 33rd parallel? • Avg temperature in “warm weather” states was above freezing in January 2014 • 139 MLB Pitchers from warm weather areas • 108 MLB Pitchers from cold weather areas • A higher proportion of MLB pitchers undergoing UCLR are from warm weather areas p<.0001 2014 Pitchers from warm weather areas had UCLR one year earlier than cold weather pitchers Pitchers from warm weather areas pitched significantly fewer MLB season prior to UCLR 2014 2014 • 505 examinations on 296 pitchers for 8 consecutive years (2008-2005) ➢ Measured pROM of throwing/non-throwing shoulder • 49 elbow injuries and 8 elbow surgeries in 38 players ➢ Missed 2551 days because of this • Pitchers w/ deficits of >5° in total rotation in their throwing shoulder had a 2.6 times greater risk for injury • Pitchers w/ deficit of >5° in flexion of the throwing shoulder had a 2.8 times greater risk for injury • In this study, GIRD was not correlated w/ injury • Purpose: determine factors predictive of UCLR among MLB pitchers • Pitch velocity, number, and type (fastball, curveball, etc.) for every pitcher and game within MLB from 2007 to 2015 • 1327 pitchers included; 309 (26.8%) had undergone UCLR • Peak pitch velocity was significantly higher among preinjury pitchers than control pitchers: 93.3 vs. 92.1 mph P<.001 • Same w/ avg pitch velocity: 87.8 vs. 86.9 mph P=.001 2016 2019 2010 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Fastball Velocity is INCREASING 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Percentage of Fastballs Thrown is DECREASING 2002 • Purpose: evaluate association between pitch counts, pitch types, and pitching mechanics and shoulder and elbow pain in young pitchers • Followed 476 baseball pitchers (ages 9 to 14 years) for one season • Authors collected data from pre- and postseason questionnaires, injury and performance interviews after each game, pitch count logs, and video analysis of pitching mechanics • 50% experience shoulder or elbow pain during the season • Significant association between the number of pitches thrown per game and during the season, and rate of elbow pain and shoulder pain How much of a difference in pitch counts leads to injury? Variable History of injury No history of P injury Pitches/Game 64±21 54±22 <0.001 Pitches/Year 1978±1679 1408±1491 0.001 10 pitches per game 500 pitches per year Current Pitch Count Recommendations Age Pitch Counts Rest 17-18 105/day 31-45 pitches = 1 day rest 46-60 pitches = 2 days rest 15-16 95/day 61-75 pitches = 3 days rest 76+ pitches = 4 days rest 13-14 95/day 21-35 pitches = 1 day rest 12-13 85/day 36-50 pitches = 2 days rest 51-65 pitches = 3 days rest 10-11 75/day 66+ pitches = 4 days rest 9-10 50/day Risk Factor Summary • Pitching with higher velocity • High pitch counts • Pitching >100 innings per year • Pitching on consecutive days • Pitching for multiple teams • Pitching while fatigued • Geography (pitching while growing up in warmer climates) • Pitching with a loss of total arc of shoulder motion • Loss of hip rotation We are still learning other risk factors Physical Exam ROM: 0°-145°, 80°/80° TTP over sublime tubercle No discernable increase in laxity of UCL compared to left elbow Pain w/ Moving Valgus Stress Test, Milking Maneuver Pain with arm bar and forced elbow extension No ulnar nerve symptoms Other Diagnoses To Consider… • Ulnar Collateral Ligament Injury • Valgus Extension Overload • Osteochondral Lesion • Ulna or Medial Epicondyle Fracture • Medial Epicondylitis/Little Leaguer’s Elbow • Ulnar Neuropathy/Instability • Flexor/Pronator Injury What Is The UCL? Primary restraint to valgus force between 30°-120° of elbow flexion Anatomy was described by Morrey in 1983 Recent work has expanded our understanding on UCL insertion What Is The UCL? 3 Bundles Anterior Bundle Ant/Post Bands Posterior Bundle Transverse Bundle Hypertrophy in MLB Pitchers 2019 • Cadaver study evaluating the contribution of the varying parts of the distal UCL to valgus stability of the elbow • Dissected the UCL in 15 cadavers and sectioned the UCL in three different sections: proximal, middle, and distal thirds • The middle and distal thirds of the UCL insertion on the ulna did not significantly contribute to gap resistance at 5 Nm of valgus load. The proximal third of the footprint is the primary resistor of valgus load 2019 2019 • Excellent elbow anatomic dissection study that found two tendinous septa: one between PT and FDS and one between FDS and FCU. Both are connected to the medial part of the brachialis tendon, deep aponeurosis of the FDS, and FCU to form the tendinous complex, which linked the ulnohumeral joint • Determined the
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