ADVENTURES AND LESSONS LEARNED ON THE UCL Michael G. Ciccotti, M.D. - - PDF document

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ADVENTURES AND LESSONS LEARNED ON THE UCL Michael G. Ciccotti, M.D. - - PDF document

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ADVENTURES AND LESSONS LEARNED ON THE UCL Michael G. Ciccotti, M.D. Eastern Athletic Trainers Association Department of Orthopaedics Philadelphia, PA The Rothman Institute January 7-10, 2011 Thomas Jefferson University Philadelphia, PA

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SLIDE 1

ADVENTURES AND LESSONS LEARNED … ON THE UCL

Michael G. Ciccotti, M.D. Department of Orthopaedics The Rothman Institute Thomas Jefferson University Philadelphia, PA

NOTES I. INTRODUCTION – QUESTIONS TO BE ASKED

  • 1. What’s the big deal? (Epidemiology)
  • 2. Is it what I think it is? (Diagnosis)
  • 3. How do you fix that? (Surgical Technique)
  • 4. Coach, when can I go back in? (Outcomes and Return to Play)

II. WHAT’S THE BIG DEAL?

  • 1. MLB Statistics
  • a. ~ 1/5th of medical costs involve the elbow joint
  • b. 2nd only to shoulder joint
  • 2. Anatomic considerations
  • a. Anterior bundle is primary valgus restraint from 30° - 120°
  • 3. Biomechanical considerations
  • a. Phases of throwing – late cocking/early acceleration
  • b. Average angular velocity – 5000 deg/sec
  • c. UCL provides 70-75% valgus stability at 90°
  • 4. Epidemiology (Andrews, AOSSM/AAOS, 2007)
  • a. Occurance in elite throwers thought to be secondary to overuse/poor mechanics
  • b. Increasing # of youth and high school baseball players with UCL injury

(~ 200% increase/year since 2000 – Andrews et al, 2007)

  • c. Increased occurance or awareness?
  • d. Presumed risk factors:
  • Velocity > 80 mph (radar gun) (73%)
  • Year-round throwing (69%)
  • Early breaking pitches (67%)
  • Seasonal overuse (62%)
  • Event overuse (42%)
  • Inadequate warm-up (23%)
  • 5. Epidemiology Studies … provide insight on athletes at risk

III. IS IT WHAT I THINK IT IS?

  • 1. History
  • a. Repetitive throwing
  • b. Pain during late cocking/acceleration phases
  • c. +/- sudden pop

Eastern Athletic Trainers Association Philadelphia, PA January 7-10, 2011

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SLIDE 2

NOTES

  • 2. Physical examination
  • a. Tenderness over UCL
  • b. Pain with valgus stress
  • c. + Milking Test
  • 3. Imaging
  • a. Plain x-rays (AP, lateral, oblique, axial)
  • Asymptomatic abnormalities exist
  • b. Stress x-rays (manual vs. Telos)
  • >2-3 mm opening compared to contra-lateral elbow.
  • Asymptomatic abnormalities exist
  • c. MRI
  • Non-enhanced requires special sequences
  • Enhanced with improved sensitivity, especially partial tears
  • Studies suggest asymptomatic abnormalities occur
  • Studies indicate that injury (especially deep and partial thickness) may be missed
  • d. Ultrasound
  • Safe
  • Rapid
  • Non-invasive
  • Less expensive
  • Dynamic
  • e. “Stress Ultrasonography of the UCL in Elite Baseball Players” (Nazarian and Ciccotti,

2006 and 2008)

  • 155 pro baseball players undergoing DUS at spring training over 6 year period
  • UCL evaluated for thickness, hypoechoic focii, calcifications, and joint space

width (at rest and stressed with Telos at 30°)

  • In dominant elbow of asymptomatic, elite pitchers, UCL was:
  • thicker
  • more hypoechoic signals
  • more calcifications
  • 70% of players with multiple DUS showed increased joint space gapping with

time

  • No increase in hypoechoic signals/calcifications with time
  • Players who subsequently incurred a UCL injury had significantly increased:
  • joint space gapping (>1 to 1.5 mm)
  • calcifications

… compared to asymptomatic players

  • DUS may provide a predictive profile of player at risk
  • 4. Diagnostic evaluation … continues to improve
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SLIDE 3

NOTES IV. HOW DO YOU FIX THAT?

  • 1. Nonoperative treatment
  • a. Rest
  • b. Heat/Ice/NSAID
  • c. AROM when pain free
  • d. Strengthening follows
  • e. Throwing program at 6-12 weeks
  • 2. Operative Indications
  • a. Throwers with complete tear
  • b. Throwers with partial tear unresponsive to nonop treatment
  • c. Nonthrowers with ADL symptoms
  • 3. Operative Techniques
  • a. Repair – poorer results compared to reconstruction

(Conway, JBJS, 1992; Andrews, AJSM, 1995)

  • b. Jobe Technique
  • Original Procedure
  • Reconstruct ant. bundle of UCL
  • Flex-Pron mass detached
  • Bone tunnels in ulna and med. epi (into cubital tunnel)
  • Free tendon graft in “Figure-of-8” fashion
  • Ant. submuscular transposition of ulnar nerve
  • Andrews Modification
  • Elevate flex-pron tendon without detaching
  • Same ulnar and med. epi. tunnels
  • Subcutaneous ulnar nerve transposition
  • Yocum Modification
  • Flex-Pron muscle-tendon split without detaching
  • Same ulnar tunnel
  • “Y” shaped med. epi tunnel with exit through separate ant. third split

in flex-pron mass (not into cubital tunnel)

  • No ulnar nerve transposition
  • c. Docking Technique
  • Flex-pron muscle-tendon split
  • Same ulnar tunnel
  • Single humeral tunnel in med. epi
  • Krakow stitch tendon fixation
  • d. Alternative Techniques
  • Implant Fixation (Hechtman et al, AJSM, 1998)
  • Free Tendon Graft
  • Suture anchor fixation in med. epi + ulnar bone tunnels
  • Suture anchor fixation in both hum. + ulna

… limited data available

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SLIDE 4

NOTES

  • DANE Procedure (Conway, AOSSM, 2003)
  • Free Tendon Graft
  • Flexor-Pron muscle-tendon splitting
  • Docking technique in Humerus
  • Single tunnel in ulna with biotenodesis screw fixation

… limited data available; simpler technique with decreased OR time

  • 4. Biomechanical Comparison (RI)

“A Quantitative Evaluation of Two Reconstructive Techniques of the Ulnar Collateral Ligament”

  • A. 12 pairs of fresh frozen cadaver elbows
  • B. 3 degree of freedom loading device
  • C. potentiometers, torque sensors
  • D. 6 underwent Jobe technique; 6 underwent Docking (matched elbows)
  • E. Results:
  • Load to Failure: Native UCL>Jobe, Docking
  • Load to Failure: Jobe = Docking
  • Flexibility of Native UCL, Jobe, Docking all similar at 90 degrees
  • 4. Surgical Techniques … continue to evolve

V. COACH, WHEN CAN I GO BACK IN?

  • 1. Postoperative Rehabilitation
  • A. Splint for 7-10 days
  • B. Hinged elbow brace for additional 2-4 weeks
  • C. Batting at 3 months
  • D. Tossing at 4 months
  • E. Throwing from mound at 6 months
  • F. Return to play 10-16 months
  • 2. Does the end justify the means?
  • Original Jobe Technique (Conway et al, JBJS, 1992)
  • 56 pts
  • mean F/U = 6.3 yrs
  • 80% good/excellent
  • 68% return to pre-injury level at mean of 12 months
  • 12 of 16 professional pitchers returned
  • 22% with postop ulnar nerve symptoms
  • Andrews Modified Jobe Technique (Azar et al, AJSM, 2000)
  • 59 pts
  • min F/U = 12 months
  • 81% returned to pre-injury level at mean of 9.8 months
  • only 1 pt. with postop ulnar nerve symptoms which resolved
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SLIDE 5

NOTES

  • Yocum Modified Jobe Technique (Thompson et al, ASES, 2001)
  • 83 pts (54 professionals, 18 collegiate, 11 recreational)
  • 94% good/excellent
  • 82% return to pre-injury level at mean of 13 months
  • 5% with postop ulnar nerve symptoms - all transient
  • RI experience (Yocum Modified Technique)
  • 54 pts (31 pitchers)
  • avg F/U = 34m (12-62m)
  • 88% with FROM (90% of pitchers)
  • 92% return to pre-injury level

(87% of pitchers) at mean of 11 months

  • no postop ulnar nerve symptoms
  • Docking Technique (Rohrbough et al, AJSM, 2002)
  • 31 pts
  • avg F/U = 2.6 yrs
  • 97% return to pre-injury level
  • no postop ulnar nerve symptoms
  • Overall outcomes
  • High % return with minimal ROM deficits
  • Younger athletes may have difficulty advancing
  • 3. Return To Play Data (Cohen, Sheridan, Ciccotti AOSSM, 2008; Sports Health, 2010)
  • A. we may not be as good as we think
  • B. 50% returned to pre-injury level at 2 years
  • 4. Complications Data (Andrews, AOSSM/AAOS, 2007)
  • A. 449 pts undergoing UCL Recon from 1994-2005
  • B. Types of complications:
  • Postop ulnar symptoms (7.3%)
  • Non-specific elbow pain (5.1%)
  • Posterior Impingement (4.9%)
  • Arthrofibrosis (4%)
  • Retear of UCL recon (2%)
  • Flex-pron symptoms (1.8%)
  • Med. epi. Avulsion fx (1.3%)
  • C. Return to play
  • Overall (84%)
  • Ulnar nerve symptoms (84%)
  • Arthrofibrosis (72%)
  • Non-specific elbow pain (70%)
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SLIDE 6

NOTES

  • Secondary post-op impingement (50%)
  • Medial epicondylar avulsion (50%)
  • Chronic flex-pron symptoms (50%)
  • Retear of UCL Recon (22%)
  • 5. Outcomes and Return to Play … may not be as good as we think

VI. WHAT HAVE WE LEARNED? … Case Presentation VII. SUMMARY

  • 1. What’s the Big Deal?

… epidemiology provides insight on athletes at risk

  • 2. Is it what I think it is?

… diagnostic evaluation continues to improve

  • 3. How Do You Fix That?

… surgical techniques continue to evolve

  • 5. Coach, When can I go Back In?

… outcomes and return to play may not be as good as we think

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SLIDE 7

NOTES REFERENCES:

  • 1. Andrews JR, Wilk KE, Satterwhite YE, et al: Physical examination of the thrower’s elbow.

J Orthop Sports Phys Ther 17: 296-304, 1993.

  • 2. Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries
  • f the elbow in athletes. Am J Sports Med 28: 16-23, 2000.
  • 3. Cain EL, Dugas JR, Wolf RS, Andrews JR: Elbow Injuries in Throwing Athletes: A Current

Concepts Review. Am. Journal of Sports Med. 31(4): 621-635, 2003.

  • 4. Chen FS, Rokito AS, Jobe FW: Medial Elbow Problems in the Overhead-Throwing Athlete.

J AAOS 9(2): 999-113, 2001

  • 5. Ciccotti MG, Jobe FW: Medial Collateral Ligament Instability and Ulnar Neuritis in the

Athlete’s Elbow, AAOS ICL, Vol. 48: 21-31, 1999.

  • 6. Ciccotti MG, Seigler S, Kuri JA, Thinnes JH, Murphy D: A Comparison of the Biomechanical

Profile of the Intact Ulnar Collateral Ligament with the Modified Jobe and the Docking Reconstructed Elbow – an in vitro study. Am J Sports Med. 37(5):974-981, May, 2009.

  • 7. Ciccotti MG, Nazarian LG et al: Dynamic Ultrasound of the Anterior Band of the Ulnar

Collateral Ligament of the Elbow in Asymptomatic Major League Baseball Pitchers, Radiology: 149-154, April, 2003.

  • 8. Cohen SB, Sheridan S, Ciccotti MG: Return to Sports for Professional Baseball Players After

Surgery of the Shoulder or Elbow. Sports Health: A Multidisciplinary Approach, Accepted September 2010.

  • 9. Conway JE, Jobe FW, Glousman RE, et all: Medial instability of the elbow in throwing athletes.

Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg 74A: 67-83, 1992.

  • 10. Fleisig GS, Andrews JR, Dillman CJ, et all: Kinetics of baseball pitching with implications about

injury mechanisms, Am J Sports Med 23: 233-239, 1995.

  • 11. Jobe FW, El Attrache NS: Treatment of ulnar collateral ligament injuries in athletes, in Morrey

B(ed): Master Techniques in Orthopaedic Surgery: The Elbow. New York, Raven Press, 1994, pp 194-168.

  • 12. Jobe FW, Stark H, Lombardo SJ: Reconstruction of the ulnar collateral ligament in athletes.

J Bone Joint Surg 68A: 1158-1163, 1986.

  • 13. Morrey BF: Applied anatomy and biomechanics of the elbow joint. Inst Course Lect 35: 59-68,

1986.

  • 14. Morrey BF, An KN: Functional anatomy of the ligaments of the elbow. Clin Orthop 201: 84-90,

1985.

  • 15. Morrey BF, An KN: Articular and ligamentous contributions to the stability of the elbow joint.

Am J Sports Med 11: 315-319, 1983.

  • 16. Morrey BF, Tanaka S, An KN: Valgus stability of the elbow: A definition of primary and

secondary constraints. Clin Orthop 265: 187-195, 1991.

  • 17. Rohrbough JT, Altchek DW, Hyman J, et al: Medial collateral ligament reconstruction of the

elbow using the docking technique. Am J Sports Med 30: 541-548, 2002.

  • 18. Thompson Wh, Jobe FW, Yocum LA, et al: Ulnar collateral ligament reconstruction in throwing

athletes: Muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 10: 152-157, 2001.

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