ADVENTURES AND LESSONS LEARNED ON THE UCL

Transcription

1 ADVENTURES AND LESSONS LEARNED ON THE UCL Michael G. Ciccotti, M.D. Department of Orthopaedics The Rothman Institute Thomas Jefferson University Philadelphia, PA Eastern Athletic Trainers Association Philadelphia, PA January 7-10, 2011 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. III. WHAT S THE BIG DEAL? 1. MLB Statistics a. ~ 1/5 th of medical costs involve the elbow joint b. 2 nd only to shoulder joint 2. Anatomic considerations a. Anterior bundle is primary valgus restraint from 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 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 IS IT WHAT I THINK IT IS? 1. History a. Repetitive throwing b. Pain during late cocking/acceleration phases c. +/- sudden pop

2 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

3 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

4 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 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

5 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 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%)

6 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. VII. WHAT HAVE WE LEARNED? Case Presentation 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

7 REFERENCES: 1. Andrews JR, Wilk KE, Satterwhite YE, et al: Physical examination of the thrower s elbow. J Orthop Sports Phys Ther 17: , Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 28: 16-23, Cain EL, Dugas JR, Wolf RS, Andrews JR: Elbow Injuries in Throwing Athletes: A Current Concepts Review. Am. Journal of Sports Med. 31(4): , Chen FS, Rokito AS, Jobe FW: Medial Elbow Problems in the Overhead-Throwing Athlete. J AAOS 9(2): , Ciccotti MG, Jobe FW: Medial Collateral Ligament Instability and Ulnar Neuritis in the Athlete s Elbow, AAOS ICL, Vol. 48: 21-31, 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): , May, 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: , April, 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 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, Fleisig GS, Andrews JR, Dillman CJ, et all: Kinetics of baseball pitching with implications about injury mechanisms, Am J Sports Med 23: , 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 Jobe FW, Stark H, Lombardo SJ: Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg 68A: , Morrey BF: Applied anatomy and biomechanics of the elbow joint. Inst Course Lect 35: 59-68, Morrey BF, An KN: Functional anatomy of the ligaments of the elbow. Clin Orthop 201: 84-90, Morrey BF, An KN: Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 11: , Morrey BF, Tanaka S, An KN: Valgus stability of the elbow: A definition of primary and secondary constraints. Clin Orthop 265: , Rohrbough JT, Altchek DW, Hyman J, et al: Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 30: , 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: , 2001.

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