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AOSSM 2022 Annual Meeting Recordings - no CME
UCL Repair: When, Why and How
UCL Repair: When, Why and How
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Video Transcription
Certainly, I'm very happy to be here. I was definitely, I think, a little bit of a late adopter to UCL Repair, but from talking to friends and colleagues who I respect, many of whom are in this room, I basically started doing it several years ago, have been very happy so far with doing it in a certain population. These are my disclosures, none of which are relevant to this talk. So this is this common chart that we've all seen in many talks, showing the phases of pitching. And I think it's just important to understand, because understanding these mechanics and forces about the shoulder and elbow helps us to recognize and prevent these predictable injury patterns that we see in the throwing athlete. As we all know, the kinetic chain is very important to understand, that energy is funneled from the legs through the trunk rotation into much smaller upper extremity segments, and it's those segments that see these very high forces and torques, particularly across the elbow. The anatomy has been well described. We all know it's the anterior band of the anterior bundle. That's the primary stabilizer to valgus stress. It is three parts, but when we talk about UCL surgery, we really focus on the anterior bundle. And it's also important to remember that every pitch approaches maximum torque in the UCL complex. So you can have either acute ligament failure or certainly repetitive microtrauma as well. So some athletes will describe a pop or a moment in time injury, others will come to you just saying they're complaining of decreased stamina, velocity, control, et cetera. And that's because these valgus forces at the elbow are so tremendous and can exceed the tensile strength of the ligament at any moment. The athlete will often present with medial elbow pain, commonly they'll talk about pain during the late cocking acceleration phase of throwing. Sometimes again, it's just decreased accuracy, velocity, or control. Sometimes they present as acute, sometimes they don't. And you always want to think about ulnar nerve complaints as well in this population. For me, for my exam, I certainly assess range of motion. Don't forget many throwers lack some terminal extension, so don't let that surprise you. I tend to palpate over the UCL and determine if that's a location of pain. There are a variety of tests that you can use. I've found Shona Driscoll's moving valgus stress test to be most helpful for me. I always check resistive pronation to assess reflexive pronator issues. And don't forget to palpate the ulnar nerve. I palpate both to determine if it's a difference. One thing I was taught a long time ago is that the exam can be pretty benign if they're shut down for a period of time. So if you have an athlete that comes to you who hasn't thrown in six, seven, eight weeks, the exam can be quite frankly pretty normal. As we all know, MRIs are kind of the gold standard for evaluation. You can do it with or without contrast. I tend to do it with contrast and always make sure we write to have them inject laterally. You don't want to have them inject immediately with a contrast and give you a false pathology. So treatment options. So for non-operative treatment, I think you have to have the athlete shut down for a period of six weeks, no throwing, and then do a progressive rehab program focused on elbow and shoulder. They then get to an interval throwing program and for our pitching athletes, a mound program. There's been not a lot of studies looking at success rate of non-operative treatment, but this paper from AGSM is commonly quoted and it was a 40% success rate. So I'm not going to steal Dr. Alachosh's thunder, but you know, we're talking about UCR reconstruction. Some of the goals are we reconstruct the UCL with some type of graft. There's been multiple techniques described. I think job and docking are the most common. And then, you know, you treat the ulnar nerve based upon symptoms is how I do it. Others, based upon their approach, routinely transpose the nerve. But those are kind of the big picture concepts of reconstruction. The post-op care, oftentimes we have no range of motion for the first couple of weeks. We then start range of motion in a brace. I don't have them work with a therapist until six weeks because admittedly the reconstruction is not isometric inflection. They start tossing at four months, pitching at nine months. A lot of times it's a full year before they fully return to competition. And this is just a quick chart showing that there's been a lot of studies looking at UCR reconstruction with very positive success rates. What about UCL repair? Do the outcomes of repair compared to reconstruction? It's kind of the first question I want to know when I was first starting to think about doing these. How about the biomechanical strength of repair compared to reconstruction? Can we accelerate rehab and let some of these athletes play sooner than the 12 months I talked about? And what are the appropriate indications? So Dr. Conway, who's here, I believe I saw him earlier. He was on this paper from 1992 in AGSM and looked at, not to date you, Dr. Conway, but looked at repairs and reconstructions in general. And this is why we typically, for a long time, favored reconstruction is that they did better. 68% were able to return to the previous level than the repair group. More recently, Dr. Savoie looked at some athletes in the AGSM in 2080 published, 60 athletes. He looked at isolated injury to either the proximal end or the distal end, and they were repaired. He used anchors or drill tunnels and had pretty good results, 93% returned to the same level at six months, which is much quicker. This is Dr. Dugas' study that he presented at this meeting in 2018, looking at 58 overhead athletes who underwent UCL repair. These were revulsions of the UCL with otherwise healthy UCL tissue, and they had a vested interest in a shorter rehab, and again, much more positive results, 96% returned to the same level at an average of 6.1 months, again, which is much higher, much quicker than we're used to. And he went on to publish results in AGSM in 2019, looking at 111 overhead athletes who underwent UCL repair with internal brace augmentation. These were complete or partial revulsions of the UCL from either the sublime tubercle or the miopocondyle, again, without evidence of poor tissue quality, and 92% returned to the same or higher level of competition at a mean time of 6.7 months, with very positive KJAC scores as well. This was probably the most recent study from 2021, looking at 40 non-professional overhead athletes, again, younger athletes, mean age 17.8 years, and they were able to get 92.5% returned to play at the same level or higher at an average of 6.9 months, and again, this was a UCL repair with internal brace augmentation. And this is just a chart showing these studies, which have been done over the last several years. So what are the complications? There's some minor, some major, this was published with Dr. Dugas as well, minor complications occurred in 12%. There were mainly some ulnar nerve paresthesias, medial elbow pain, some superficial wound issues, more complex complications included ulnar nerve expellation and scar debriement following a transposition, and then primary ulnar nerve transposition and some HO excision. And these are just two studies. I point this out because it's very important. A lot of people want to know, well, biomechanically, how does it stack up? Well, there've been two good studies that show that UCL repair with internal brace augmentation has comparable biomechanical profile at the time of initial fixation compared to UCL reconstruction with docking and a modified job. So it seems to be that at time zero, biomechanically at least, there's some data that suggests that it's a good option. So this is probably, and I think for the most part, when you talk to certain patients about it, what probably moves the needle the most is it's a pretty different rehab. I got this from George Poleto when I first started doing this several years ago. So we still do no motion for the first week, but then motion begins week two around day eight. And our goal was full range of motion passively in our internal brace group at week four versus six weeks for a reconstruction group. We let them start doing throwers 10. Again, this is half as fast about the week three in our internal brace group versus six weeks at the reconstruction group. We apply metrics against six weeks for your internal brace group versus 12 weeks for your construction group. So you can see how it's moving along much faster. Interval throwing program begins week 12 in your internal brace group versus 16, week 16 of reconstruction group. And the return to play, I think we've all had athletes return to play at six, seven, eight months versus a lot of times it takes a year in our reconstruction group. What we don't know, long-term outcomes, what are the outcomes at professional level? I know that Dr. Dugas and some others have done some professional athletes, I think Dr. Poleto as well, but I certainly have not yet. And what about internal brace augmentation with mid-substance injuries or diseased ligaments? Are they more likely to fail? So I'll go through my indications. So currently right now, a UCL injury, proximal or distal avulsions only. I do not do UCL repair for any mid-substance. Obviously should have failed conservative treatment. I think the tissue needs to appear healthy on MRI as well as when you evaluate it intraoperatively. And I put this on here, I said H or MAC, and by that I mean is that some of your gymnasts or cheerleaders or even wrestlers who have sort of a more dramatic UCL injury, where I think I call it macro instability, I found that even on MRI sometimes if it appears partial, the tissue quality is much less robust. And so I found that reconstruction for that population is better. My rationale is, again, for these proximal and distal injuries, I do think we can get it back quicker. And also initially I certainly kind of cherry-picked athletes who I described as having a shorter throwing lifespan. So the senior with maybe one more year to throw, either in high school or college, maybe aren't going to throw for a long period of time, but wanted to get back quickly. That was the first group I was doing it in and was happy I did it that way. So technique, I do a flexor perimeter split. I do not routinely transpose the ulnar nerve in my repairs or reconstructions without symptoms. You want to identify the UCL, pterocyte, and make sure that, again, the tissue quality looks good. And as long as you're happy with how it looks, then you proceed with repair. You put an anchor in at the pterocyte first. That anchor is loaded with collagen tape and a 2-0 suture. It's very important to tap it several times. I learned this from Dr. Bradley. It's very hard to get these anchors down if you don't tap it on both sides. So I throw the tap down two or three times just to ensure I can get it down. And then after you put it at the site of the tear, either that's proximal or distal, then you use the suture to repair your ligament directly to the avulsion site. And then after that, you want to repair the opposite side, either proximal or distal, in a similar fashion. At this point, you do tension your fiber tape, another pearl from Dr. Bradley. You want to place a freer under that tape to avoid over-tensioning, very important. And then you insert your anchor. And then you use a—I don't do this with my reconstructions, but with repairs I do, I tack my native ligament to my brace with an interrupted suture. And real quick, just briefly, this was a case I did—one of my earliest ones was an 18-year-old high school pitcher, felt an acute pop during the game. He was not going to play collegiately, and he had one more season left. His exam was positive. It was a distal UCL injury. We talked about the pros and cons of a repair versus reconstruction. You can see that kind of classic T sign, an injury at the sublime tubercle. This was one of my earlier UCL repairs with the brace augmentation, and he was able to return to play at six months without issue and was very happy. So thanks. Great. Thank you.
Video Summary
The speaker in the video discusses the topic of UCL repair in throwing athletes. They explain that UCL repair is a surgical option for athletes who experience UCL injuries, particularly proximal or distal avulsions. The speaker presents studies that show favorable outcomes for UCL repair, with athletes returning to the same or higher level of competition in a shorter time compared to UCL reconstruction. They discuss the post-operative care and rehabilitation process for UCL repair, which involves a faster progression compared to UCL reconstruction. The speaker mentions some complications associated with UCL repair and highlights the importance of evaluating tissue quality before proceeding with the repair. They conclude by stating that long-term outcomes and the use of internal brace augmentation for mid-substance injuries are still areas that need further study. No credits were mentioned in the video transcript.
Asset Caption
Christopher Dodson, MD
Keywords
UCL repair
throwing athletes
proximal avulsions
distal avulsions
post-operative care
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