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IC108-2021: Management Of Ulnar Collateral Ligamen ...
Management Of Ulnar Collteral Ligament Tears: Wher ...
Management Of Ulnar Collteral Ligament Tears: Where Do We Stand in 2021? (4/4)
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It's it's it's got a little something for everybody from those who are just starting to do this operation and those that I've been doing it for 30 years and I look at the table over here on my left and some very esteemed colleagues who've Got more experience than I do at this and thanks for coming and listening go easy on the questions guys just a few disclosures As Brendan pointed out and we've learned a lot about the ulnar collateral ligament Over the last 10 years and you think about this when most of us who've done this for a while first started doing ulnar collaterals It seemed like any athlete that had sprained their ulnar collateral ligament got a reconstruction I mean no matter the level of play no matter the degree of the injury We're doing a lot of them and you think about where we are today and we've really drilled this down to you know A science we're getting very granular. We understand now that they're not all the same, you know They behave differently based on their location. They behave differently based on the on the severity of the injury So we're not operating on as many of these as we used to and now we can repair some of them Which is fantastic. So, you know good for us and good for our patients What we've what we've learned over the years and it is important I think to be selective and it is important to understand the difference between the You know the severity of a partial proximal injury versus a complete distal injury and we do treat those differently In general and these are very general Suggestions to consider when we're evaluating these athletes when we're making treatment decisions. These are the things that I look at You look at the age of the athlete their sport their position We know most of these are baseball players their level of play We consider the time of the season and the time of their career also Anatomically, we're looking at the location of the injury the degree acute versus chronic a lot of these are acute on chronic Associated elbow pathology and associated other pathology and Chris Ahmad is going to speak to that later in his talk As a suggestion, you know when I'm first looking at these athletes and everybody's treated as an individual But in general non-operative treatment is considered as an initial approach and someone who's young lower level of play and non pitcher perhaps earlier in their season a low-grade proximal injury or maybe a late career pro athlete that doesn't Want to have you know, the 16 month recovery these a lot of those are ending up with repairs if they're indicated We're more likely to proceed with an initial approach in surgery in a more mature high-level professional athlete who's a pitcher Certainly some somebody who's late in their offseason and a high-grade distal injury. We know those don't behave particularly well And most of those are going to require Either repair or reconstruction. So this is what I'm talking about. So this is a 17 year old high school outfielder I Made a hard throw from center field felt a pull no pop able to finish the game pretty sore and tight the next day You know fortunate enough to have a have have good good insurance. We get it. We get an MRI scan You know, and this is what we see. So we see a proximal injury. It's an incomplete injury We see some periligamentous edema and we elected a non-operative course of treatment for this. This is my typical treatment for this sort of a case We'll contrast that with this image, this is a 20 year old college pitcher It's April of his junior year had a sudden acute pop Well throwing swelling and pain the next morning markedly positive exam pretty impressive MRI scan He's got a little contrecoup injury on the lateral side there. You can see he's actually bruised his radial head He's got a complete distal injury on the medial side. This is a reconstruction or a repair I think all day in my hands So these are the things we consider when we're trying to advance the science of ulnar collateral ligament reconstruction, you know We think about the anatomy. I have a particular interest in the insertion sites as Jeff alluded to the biomechanics augmentation which Jeff is Is really leading the way with regards to that and then biology is also going to be important Orthobiologics right now are kind of on hold by the FDA. We're not doing much with these right now You know other than PRP and we know that that doesn't seem to help a whole lot in these athletes So we've got a long way to go with regards to to biologics. So just in general I'll talk a little bit about my technique. I like a docking technique. Everybody in the room is familiar with that You know, it's it's a socket on the humeral side and the two little exit holes for your traction sutures You know, the other options include those are listed below traditional job three ply There's there's scattered studies on interference screws. We'll talk about some of these results suture anchors suspensory buttons All these things have been tried but by and large the docking technique is is the most widely used This is an interesting little study back in 2016 Indicating at the insertion point and not the intrinsic differences in the ligament determine the function of the anterior bundle of the UCL This isn't this isn't widely spoken about but what this does is demonstrates that a biomechanical rationale For UCL reconstructions using a single point anatomic insertion is important And I think we need to start looking at ways to get better anatomic reconstruction distally and The repair technique that Jeff does I think addresses this somewhat certainly on the owner side for sure And we did a study looking at at the at the safe angles to to do Single point fixation with suspensory button on the on the owner side and Recommend that we have 30 degrees distal angulation and 60 degree poster angulation and every time That's reproducible Keeping you out of the proximal radial ulnar joint so keeping you out of trouble if you do decide to do suspensory button and We've got some some further work to do on that as well A graph choice palmaris the ipsilateral palmaris is the most common you can use a contralateral palmaris just a Food for thought if they've got an insufficient palmaris on their up on their ipsilateral side They're not going to have a better one on the opposite side So you're wasting your time going to the other going to the other wrist Prep their leg and go for the gracilis. I use the contralateral gracilis The ones that are listed below that the plantarus Achilles. Those are all really crappy graphs So do your best to avoid those and I've used them and they don't work particularly. Well, I Like using a single incision through a tennis stripper. You were quick to make multiple incisions that we need to Beware in the younger athletes There's a lot of these little fascial bands that run between the palmaris longus and the FCR You want to get in there and look and be very careful? And release those before you just go jamming that stripper down down their forearm. Just take your time And you can often you know, most of the time I can get it through through this single incision Well, I always find the medial lateral brachycutaneous nerve It almost always runs next to that big vein that you see right there and it's right where you need to be working So and we isolate that I put a little vessel loop around it and pull it out of harm's way I prefer to split and just the way we do it and as a result of that we don't necessarily have to transpose the nerve That's just my my personal my personal technique. There's nothing wrong with doing Doing the ulnar nerve transposition, you know, Jeff does a lot of that and has outstanding success You know, the muscle splitting approach is basically between the FCU and the FDS and it is a safe approach And it gets you where you need to go This is what it looks like though The nerves been exposed simply so we can kind of keep an eye on it and keep it out of harm's way as we're working Getting back to the anatomy going distal when distal what's that mean? Well, you know Jeff showed that slide from one of their studies looking at the origin and insertion of the ulnar collateral ligament a study that we published many years ago demonstrated how long the Attachment is on the ulnar side. It doesn't just stop at the sublime tubercle It goes another two centimeters down along that ulnar collateral ligament Ridge You can take advantage of that and that's very handy to know particularly in a revision situation But I'll show you how we address that with our with our primary tunnels. This is the location that we want to be at Sublime tubercle is is marked with the down arrow and the Ridge is the are the double arrows there And this is basically where you want to be and how you get there Through that muscle split. That's a sublime tubercle ulnar collateral ligament Ridge right here I like to put my guide at the transition between the sublime tubercle and that Ridge just as it starts to become that Ridge You can palpate that you can visualize it pretty well And yeah, I like to use this little two-point guide this intersecting guide gets us gets us the tunnels we need Carefully curette that out with with a curved curette make sure you've got a good bone bridge there You want to be too aggressive there? You don't want to crack that Leads leads to some problems So we'll irrigate that out and make sure all the little bone dust is out of there And then I'll take this needle and pass this and we use this to pass a passing suture That will then be used to pull our graft down Into our tunnels and secure it on the ulnar side Jeff was referring to this earlier stay lateral and proximal. What's that mean Chris Ahmad? Who's on our panel did some very nice work on this looking at these insertion sites? You know you think about all the work that's been done on the ACL and the PCL And you know everybody knows where those things are supposed to go It seems like many of us don't really understand where the ulnar collateral ligament goes as Jeff pointed out It's important to do this though. It's important to know you know where to put this and most of the mistakes are Going to be to Prox or to to posterior and to medial that's the area you don't want to get into you want to you want to make sure your anterior and Lateral so where you want to be is down there You don't want to be on that tip as Jeff pointed out you want to be down in that that little angle between the epicondyle And the rest of the distal humerus, that's the location that you want to be at That sets you up. You know for this and and and we'll go through that as we come along So here we are looking at that same elbow Pretty aggressively going after getting that soft tissue out of there And my curette is on that flat spot that anterior facet And it's right down there in that little corner where that transition is for me I use the intermuscular septum sort of as my guide To to get this in the right orientation You know and again you don't want to be too posterior you blow that out And you don't want to be too too on the medial side, and we use this other little intersecting guide To create our smaller holes that we're going to use for our traction sutures We've my PA is holding the nerve out of the way As we come up with that that other small drill once again We'll irrigate that out and get all our bone dust out of there And use these little these little these little skids and and suture passers to to pass our sutures And we'll go ahead and pull our graft in on the owner's side And then we'll take our good end the one that's been That's been sutured and pull that up into the socket And then we'll measure and mark on the on the loose end ours our second traction suture That will then be used to pull the second limb up into the humeral socket Going for three simply means not cutting off that extra graft if you can do it I like to stuff that and don't overstuff it, but I like to have that those three strands in there So we'll let that extra strand fall back down And you get this little three ply look to that if you've got a lot of extra length on that you can try to pass That through the owner's side again. It's difficult But you can do it. I don't think it's necessary, but you can do that and then you sew these limbs together All three of them, and I also incorporate then the native ligament as well usually you can get the anterior Portion of ligament there you'll be careful Trying to sew that posterior leaf in there the nerve is right underneath all that so you want to just be cautious with that I like a poster splint for about about a week or so And then we put them on orthotic. You know basically where they're where they're comfortable you want to have their motion By a month if you don't have it at six weeks You've got what you've got you don't gain motion in an elbow after six weeks typically you need to be aggressive with this And we initiate a plyometric program 12 to 14 weeks and interval throwing program anywhere from 14 to 16 weeks Depending on how they're doing So how are we doing with all these operations as Brandon pointed out? We sure do a lot of them. Are we helping people? Well actually we are not everybody though, I mean you know the results are okay, this is a study of the Birmingham groups experience 313 players 10-year follow-up that 83% number seems to be out there and a lot of different systematic reviews It's a pretty consistent number as you look across the literature Mean career, I think this is a really interesting part of this study is a mean career length of 3.6 years with professionals lasting a little longer than the college athletes and 86% retired for other reasons Other than elbow problems and typically for shoulder problems. This is one of Brandon studies Looking at the outcome in Major League Baseball. Here's that 83% again showing up So and pretty similar to the Andrews group Study that we just looked at with an average career length of about 3.9 years so very consistent Reporting here It's interesting. You know you see significant performance improvements across the board That's not surprising to anybody because if you've got a you've got a bad ligament in your elbow and you're pitching you're probably not going To be particularly good, and then you make it better by reconstructing and repairing it and lo and behold you're able to pitch again So it works out pretty well This is a very interesting study out of out of Kajak That Neil published a couple of years ago And I think the key take-home here is that the technique performing the graph type used did not affect performance So it doesn't matter if you're good at what you're doing stick with it. Don't get fancy as dr. Andrews will say you know do what got you there, and you're gonna be okay You know some interesting little tidbits that came out of that as well Pitchers with palmaris graphs returned at a higher rate than those with gracilis graphs who really knows why that would be Pitchers who had partial tears had worse performance before injury and after reconstruction you know again Not not exactly certain how that would be and chronic tears also giving an improvement in the RA with reconstruction Another interesting study by by Brendan This was a question. I'm sure came up at a meeting. We're talking across the table, and you know hey does it matter You know so do outcomes or subsequent injuries differ UCL with a palmaris versus a hamstring a little bit Players who underwent UCL are with hamstring were more likely to sustain a subsequent lower extremity injury So it's an interesting bit of data. I think No difference in performance or return to sport whether you do a Hamstring or palmaris again consistent. I think with the k-jock work that's been done, so it's nice to see reproducible results Return to play and return to sport after MLB position players interesting data here from from from the Houston group Looking at MLB position players versus pitchers Demonstrating their position players came back at about the similar rate as pitchers did Catchers has to give any different shorter career length and match controls outfielders perform worse versus pre-op Some interesting work here by Chris Ahmad Looking at the effect of pre-draft UCL reconstruction on performance of professional baseball this comes up every year You know is a kid better off having his elbow reconstructed or is he is he more draft eligible if he doesn't have a reconstructed? And what does it mean? This is good data here for those of us who review those sorts of charts Demonstrating the professional pitchers who had a UCL reconstruction as amateurs so pre-draft actually perform as well Maybe even better than their colleagues who did not have elbow surgery This is a study that the Brennan took on and this did come from a conversation. We had at a meeting one day And this is a I think very interesting data looking at Return to hitting following UCL reconstructions, and it takes a while for these guys to come back But they're hitting a little earlier than they're playing only 77% were able to return to hitting in a real game So those numbers are a little lower than we see with that 83% return to play in the pitchers But this is this is good data as well Almost almost done boring you with with with with the literature here I told you I'd talk to you about some of the outcomes of some of these other techniques this is the really the only study that's done looking at the outcomes of interference screw fixation In ulnar collateral ligament reconstruction 19 of 22 excellent results by the Conway score dr. Conway who's joining us today Pre-injury level play for at least one season so decent results in that This is a the only study I found looking at UCL reconstruction with double suspensory button technique Of note they had no ulnar nerve symptoms Which you would think would be the probably the biggest risk with that technique on the ulnar on the humeral side Putting that button over the back so be interesting to drill down into this and look at their technique You know exactly where they're putting that button up on the ulnar side This was referred to earlier on Hamstring reconstruction Most of us aren't doing this as a primary operation But it does show good results in the hands of an extremely skilled surgeon as published by buddy back in 2013 a couple things just to finish up with we didn't we didn't talk about revisions other than the fact that they're a nightmare to do the first publication on revision ulnar collateral ligament reconstruction outcomes came out of curl and Job Only 33% return to play as Jeff pointed out miserable operation to do And very you know very challenging for everybody involved 40% complications a lot of them related to the nerve more contemporary data in 2015 out of the Henry Ford group looking at 33 pitchers In MLB who underwent revision they did a little bit better with 65% return to play But a shorter career length and Performance metrics aren't quite as Quite as robust either, so that's all I have thank you very much, and I think we'll have Chris do his do his video next
Video Summary
In this video, a speaker discusses the advancements in understanding and treating ulnar collateral ligament (UCL) injuries in athletes, particularly baseball players. The speaker emphasizes that not all UCL injuries are the same and should be treated differently based on factors such as location and severity of the injury. The speaker explains that while reconstruction surgery used to be common for UCL injuries, now there is a trend towards repair and non-operative treatment when appropriate. The speaker also discusses different surgical techniques and graft choices for UCL reconstruction. Several research studies are referenced to support the effectiveness of UCL reconstruction in improving performance and allowing athletes to return to play. The speaker also touches on the challenges and outcomes of revision UCL reconstruction. Overall, the video provides an overview of the current understanding and management of UCL injuries in athletes. -<br /><br />No credits granted- This summary is an original work.
Asset Caption
Mark Schickendantz, MD
Keywords
Ulnar collateral ligament injuries
Athlete injuries
Baseball players
UCL reconstruction
Non-operative treatment
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