A systematic review of surgical outcomes of ulnar collateral ligament rupture in the elbow treated with various techniques

Ben Nagy; Jacob Alexander; Jiayong Liu

doi:10.1016/j.jor.2024.11.007

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64 (); 1-6

doi:

10.1016/j.jor.2024.11.007

A systematic review of surgical outcomes of ulnar collateral ligament rupture in the elbow treated with various techniques

Ben Nagy, Jacob Alexander, Jiayong Liu

University of Toledo Medical Center, Department of Orthopaedic Surgery, USA

⁎Corresponding author: Jiayong Liu. jiayong.liu@utoledo.edu

Received: 2024-10-14, Accepted: 2024-11-9, Published: 2024-11-14

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

When comparing different techniques, there is limited evidence on return-to-play rates and complication rates following ulnar collateral ligament (UCL) surgery. This systematic review aims to assess the outcomes of various UCL surgery techniques. A systematic search of PubMed, Google Scholar, and EMBASE up to May 2024 was performed. Outcome measures included return-to-play rates and postoperative complication rates from relevant articles. Data was analyzed using a chi-square analysis to determine statistical significance. Internal bracing repair demonstrated a return-to-play rate of 93.2 % at the same or higher level of competition, outperforming the rates of 80.5 % for the modified Jobe technique and 82.3 % for docking reconstruction. The docking technique exhibited a minor postoperative complication rate of 2.35 %, significantly lower than the rates of 8.59 % and 8.08 % for modified Jobe and internal bracing techniques, respectively. The modified Jobe technique had a major postoperative complication rate of 1.16 %, while internal bracing had a rate of 3.01 %. The use of internal bracing for anchor repairs demonstrated a statistically significant higher return-to-play rate at the same or elevated levels of competition compared to the reconstruction techniques analyzed. Notably, the docking technique exhibited a significantly lower rate of minor postoperative complications when contrasted with both the modified Jobe and internal bracing methods. Furthermore, the modified Jobe technique was associated with a significantly reduced incidence of major postoperative complications compared to the internal bracing approach.

Keywords

Ulnar collateral ligament (UCL) rupture

Modified jobe

Docking

Repair with internal bracing

Outcomes

Show Related Articles from PubMed

1 Introduction

With Frank W. Jobe's introduction of a novel figure-of-8 reconstruction with autografting in 1986, reconstruction has served as the primary surgical method for UCL injuries.¹ Due to a high rate of ulnar nerve complications, modifications to this technique, known as the “jobe” technique, have since been developed. These modifications involve changes such as transposing the ulnar nerve subcutaneously as opposed to submuscularly,²^,³^,⁴ directing the tunnels drilled in the humeral medial epicondyle more anteriorly to avoid having to transpose the ulnar nerve all together,⁵ and using a muscle splitting approach on the flexor-pronator mass to avoid having to detach the muscle mass completely.²^,³^,⁴ Despite these modifications and improvements to the Jobe technique, structural compromise caused by three large drill holes located on the humerus persisted, along with difficulty in maintaining tension on the graft due to being stitched upon itself.⁶^,⁷ This led to the development of the docking technique in 2002 by David Altcheck.⁷ In the docking technique, instead of three larger holes being drilled in the medial epicondyle of the humerus, one large hole and two smaller holes are created to pull through sutures attached at the end of the graft, thus allowing the surgeon to maintain tension in the graft while tying the sutures over a bone bridge.⁷ These modifications reduce the risk of fracture by preserving more of the humeral bone,⁸^,⁹ increase the ability to maintain graft tension,¹⁰^,⁷ and are more surgeon friendly.¹⁰^,⁸^,⁷ These construction techniques have become increasingly popular due to poor outcomes regarding return to play rates associated with UCL repair. In 2000, Azar et al. discovered that amongst baseball players, those who underwent the modified Jobe reconstruction technique had an 81 % return to the same level of competition or higher, while those who underwent UCL repair had a return rate of only 63 %.² In 2013, augmentation with an internal brace was utilized during UCL repair.¹¹ Repair with internal bracing provides a surgical alternative to acute UCL injuries, especially for those with healthy tissue and that lack ligament deterioration that can result from excessive pitching.¹²^,¹³^,¹⁴^,¹⁵^,¹⁶ Additionally, the internal brace contains collagen to enhance biological healing,¹²^,¹⁶ provides stability to valgus stress,¹² and eliminates the waiting period for graft incorporation following surgery,¹⁵ which all provide a patient the ability to proceed with rehabilitation sooner. In order to compare outcomes of these surgical techniques, the rates of return to play to the same level of competition or higher and postoperative complications across sources have been compiled (see Figs. 1–3).

Illustration of the modified Jobe technique. Also known as the Jobe reconstruction or Jobe's technique, it is a surgical procedure used to repair a ruptured ulnar collateral ligament (UCL) in the elbow, particularly common among athletes involved in overhead sports, such as baseball pitchers.

Illustration of the Docking technique. It is a surgical method used for the reconstruction of the ulnar collateral ligament (UCL) in the elbow, particularly in athletes who have sustained a complete rupture of the ligament. This technique is an evolution of previous surgical methods, aiming to improve outcomes and reduce complications.

Illustration of the internal bracing technique. It is a newer surgical approach designed to enhance the stability and healing of the UCL, particularly in athletes who have sustained a UCL rupture. This technique allows for a less invasive procedure, potentially reducing recovery time and improving outcomes.

2 Methods

A systematic search of PubMed, Google Scholar, and EMBASE up to May 2024 was performed. Keywords for search included “ulnar collateral ligament” “UCL” “modified Jobe” “docking” “reconstruction” “internal bracing” “repair” and “return to play.” Data was extracted by independently by first author and compiled in Google Sheets. Return to play rates, time to return to play, and postoperative complications occurrences and rates were extracted. A source's return to play rate was included only if it specified return to the same level of competition or higher. Time to return to the same level of play or higher was only included if a source clearly stated it was the time to reach the same level of previous competition. “Excellent” Conway scale classifications were included in return to play rate, as this states the player was able to return to play at the same level of competition or higher. Complications were divided into minor and major postoperative complications. Minor postoperative complications included those resolved without return to the operating room, such as transient hematomas, post-op ulnar nerve distribution symptoms, post-op median nerve distribution symptoms, post-op saphenous nerve distribution symptoms from graft harvest, post-op medial elbow pain, graft site complications or infections resolved with antibiotics. Major postoperative complications included those which required return to the operation room, such as ulnar nerve transposition, revision to the original surgery, or irrigation/debridement of a postoperative infection. Complications relating to heterotopic ossification, future elbow surgeries or reconstructions, retears, adhesions, fractures, or unspecified debridements were excluded from postoperative complications as there is uncertainty about whether these outcomes resulted from the surgical procedure.

3 Results

The number of patients that returned to the same level of play or higher from each included source was added to Google Sheets under the appropriate surgical technique (Table 1). Totals for each surgical technique were determined (Table 2). Using the R-project database, a chi-square analysis was performed utilizing the preoperative test function. This process was completed for both minor and major postoperative complications (Tables 3 and 4). Surgical techniques were compared, and p-values were obtained to determine statistical significance (Tables 5 and 6). A p-value of less than 0.05 was considered to be statistically significant.

Table 1 Sources included in the data analysis process.

First Author, Year	Journal	Technique	Number of patients	Follow up time	Age (years)
Azar, 2000²	Am J Sports Med	Modified jobe reconstruction vs repair WITHOUT augmentation	78 UCL reconstructions and 13 UCL repairs baseball players	35.4 months	21.6
Rothermich, 2022¹⁷	Am J Sports Med	Modified jobe reconstruction vs internal bracing repair	40 nonthrowing athletes (37 successfully contacted)	Minimum 2 years	18.0
Arner, 2018⁸	Am J Sports Med	Docking vs modified Jobe	25 modified jobe, 26 docking athletes	6.7 years	19.6
Griffith, 2019¹⁸	Am J Sports Med	Docking vs modified Jobe	566 professional baseball pitchers	At least 2 years	23.5
Camp, 2019¹⁹	Orthop J Sports Med	Docking vs modified Jobe	69 professional baseball pitchers	–	26.3
Marshall, 2019²⁰	Am J Sports Med	Docking vs modified Jobe	46 MLB pitchers	–	26.3
O'Brien, 2015²¹	J Shoulder Elbow Surg	Docking vs modified Jobe	33 athletes	3.7 years	20.3
Rothermich, 2021¹⁶	Orthop J Sports Med	Internal Bracing	353 patients	Minimum 6 month	19.1
Dugas, 2019¹²	Am J Sports Med	Internal Bracing	111 overhead athletes	1 and 2 years	18.3
O'Connell, 2021¹⁵	Orthop J Sports Med	Internal Bracing	40 nonprofessional overhead athletes	23.8 months	17.8
Dugas, 2018²²	Orthop J Sports Med	Internal Bracing	58 (66, 8 lost to follow-up) overhead throwing athletes	Followed for a minimum 1 year	17.9
Gerard, 2024¹⁴	Orthop J Sports Med	Internal Bracing	10 females UCL repairs with an internal brace	Minimum 2 year follow up	–
Cain, 2010²³	Am J Sports Med	Modified Jobe	942 contacted, 743 replied (733 reconstruction)	37 months (only those contacted)	–
Thompson, 2001⁵	J Shoulder Elbow Surg	Modified Jobe	83 athletes (33 followed for two year)	3.1 years	24.3
Dugas, 2012³	Am J Sports Med	Modified Jobe	120 pitchers	33.4±10.2 months	21.7
Osbahr, 2014⁴	Am J Sports Med	Modified Jobe	256 baseball players	12.6 years	22.1
Petty, 2004²⁴	Am J Sports Med	Modified Jobe	27 former high school baseball players	35 months	17.4
Erickson, 2016²⁵	Orthop J Sports Med	Docking and double docking	85 patients (49 docking)	60±30.8 months (includes double docking technique )	19.3
Rohrbough, 2002⁷	Am J Sports Med	Docking	36 athletes	3.3 years	23
Dines, 2012²⁶	Am J Sports Med	Docking	10 javelin throwers	28.9 months	18.5
Jones, 2013²⁷	Am J Sports Med	Docking	55 skeletally mature adolescent males	31 months	17.6
Dodson, 2006⁹	Am J Sports Med	Docking	100 overhead-throwing athletes	36 months	22
Koh, 2006²⁸	Arthroscopy	Docking	20 baseball players	41.9 months	21.7
Bowers, 2010⁶	J Shoulder Elbow Surg	Docking	21 overhead athletes	28 months	20
Paletta, 2006²⁹	Am J Sports Med	Docking	25 elite male baseball players	30 months	24.5

Table 2 Return to play to the same level of play or higher rates across surgical techniques.

	Total # of players	# of players who returned to same level of competition or higher	% of players who returned to same level of competition or higher
Modified Jobe	1637	1317	80.5
Docking	548	451	82.3
Bracing	235	219	93.2

Table 3 Minor complication rates across surgical techniques.

	Total # of surgeries	# of minor complications	% of surgeries with minor complications
Modified Jobe	1211	104	8.59
Docking	341	8	2.35
Bracing	532	43	8.08

Table 4 Major complication rates across surgical techniques.

	Total # of surgeries	# of major complications	% of surgeries with major complications
Modified Jobe	1211	14	1.16
Docking	341	8	2.35
Bracing	532	16	3.01

Table 5 Average return time to the same level of previous competition or higher across surgical techniques.

	Total # of players	Average return time to same level of previous competition or higher
Modified Jobe	249	17.00
Docking	148	16.14
Bracing	193	6.57

Table 6 The statistical significance of differences in return-to-play rates at the same or higher level and minor and major complications varies across different surgical techniques.

	Return rate to same level of competition or higher	Minor complication rate	Major complication rate
Modified Jobe vs Bracing	0.00000304	0.798	0.0118
Modified Jobe vs Docking	0.3736	0.000135	0.1668
Docking vs Bracing	0.000112	0.0007299	0.7106

Repair with internal bracing presented a 93.2 % return to play rate to the same level of competition or higher, as opposed to 80.5 % and 82.3 % for modified Jobe and docking reconstruction techniques, respectively. The docking technique presented a 2.35 % minor postoperative complication rate, as opposed to an 8.59 % and 8.08 % minor postoperative complication technique for modified Jobe and repair with internal bracing, respectively. The modified Jobe technique presented with a 1.16 % major postoperative complication rate, while repair with internal bracing presented with a 3.01 % major postoperative complication rate.

4 Discussion

Repair with internal bracing established a statistically higher return to play rate at the same level of competition or higher, and a key factor in this outcome may relate to biomechanical properties. Repair with internal bracing demonstrates consistently lower gap formation when compared to modified Jobe reconstruction during biomechanical testing.³⁰^,³¹^,³² These results are further established in a biomechanical study performed by Dugas, in which repair with internal bracing demonstrates less gap formation than the modified Jobe technique at lower cyclic loads.³¹ This lower gap formation may prove vital during early rehabilitation and return to throwing when physiological cyclic loads on the elbow are lowest. This also may help establish the ability to begin effective rehabilitation sooner, resulting in the faster return to play.¹²^,³² Although not statistically significant, repair with internal bracing has demonstrated the ability to return joint torque closer to native ligament levels when compared to the modified Jobe reconstruction,³³ which may contribute to increased likelihood of returning to play at levels a player once competed at before ligament insufficiency.

When compared to a modified docking reconstruction technique, repair with internal bracing also demonstrated less gap formation at peak torque levels, as well as greater resistance to torsional loading.³⁰ This increased resistance enables a player to proceed with rehabilitation much sooner and at a faster rate than an individual receiving reconstruction.³⁰ Although, when comparing the docking technique to repair with internal bracing, results vary, and differences in gapping between these two techniques have also demonstrated statistical insignificance.³⁴ When comparing gap formation to repair with internal bracing, docking may limit gap formation more effectively than the modified Jobe due to better ability for the surgeon to tension the graft.¹⁰^,⁷ Urch established that at 70 degrees of elbow flexion, the strain on the posterior bundle of the UCL is higher than that of the anterior bundle.³⁵ This establishes a more crucial role to valgus stability at the high flexion angles that athletes experience when throwing.³⁵ When utilizing repair with internal bracing on the posterior bundle, elbow kinematics, such as ulnar rotation and valgus laxity, were better restored than when a three-strand docking reconstruction was utilized.³⁵ Although, at angles of 90 degrees of elbow flexion or greater, modified Jobe and docking techniques were able to restore valgus laxity nearly equally to native ligament levels.³⁶ At angles of lower flexion, both reconstruction techniques failed to restore valgus laxity to native levels, which may provide consequences to athletes who utilize side-arm angles.³⁶ It is reasonable to assume that restoration of elbow kinematics to native ligament levels is likely crucial in athletes such as baseball players and javelin throwers to achieve success at their same prior-to-injury competition levels. Regarding the biomechanical differences between internal bracing and reconstruction techniques, it is important to note that these biomechanical testings were performed on cadavers directly after the procedures, with limited time or ability for the graft to effectively incorporate into the bone.¹⁰^,³⁰^,³⁴^,³⁶^,³¹^,³²^,³³^,³⁵

Docking established a statistically significant lower minor postoperative complication rate than the modified Jobe and repair with internal bracing. This information is crucial as patients who experience transient ulnar neurapraxia as a minor postoperative complication have demonstrated increased likelihood to retire due to elbow issues and decreased upper extremity functionality.⁴ Although minor postoperative complications varied between docking and modified Jobe, it is important to note future complication and injury rates are similar between these reconstruction techniques. This is an interesting finding because the modified Jobe has larger drill holes on the medial epicondyle of the humerus, leading to a 46 % lower perfusion rate when compared to the docking technique due to disrupted blood vessels, which may impact healing and incorporation.³⁷ Pain during the return-to-throwing phase has critical consequences, as experiencing medial elbow pain correlates to a 7 % increased rate of reoperation amongst pitchers.³⁸ Modified Jobe and docking techniques demonstrate the same rate of pain during this return to throwing phase.³⁸ Along with similar pain rates when returning to throwing, modified Jobe and docking techniques also demonstrated no differences in the rates of future elbow injuries and surgeries.¹⁹ Although our results do not highlight this idea, it is important to note that reconstruction has the added risk of complications arising from graft harvests, such as wound and nerve deficits.²⁴^,⁵ Repair with internal bracing completely eliminates this risk as no graft harvest is performed.

Regarding repair with internal bracing and reconstruction, both surgical approaches show no evidence of changed fastball velocity or “holding back” as evidenced by shortened stride, horizontal adduction, and insufficient forward trunk tilt.³⁹^,¹³ This is crucial as it may correlate to players' lack of mental and physical concern with reinjury. While modified Jobe reconstruction technique demonstrates no change to all other biomechanics of pitching,¹³ repair with internal bracing demonstrates less external rotation of the nondominant shoulder, slower maximum elbow velocity, maximum shoulder internal rotation, and maximum elbow extension following ball release.³⁹ These biomechanical changes don't impact a pitcher's velocity, but they may have consequences regarding a pitcher's control and spin rate. Further research may provide insight into whether these biomechanical throwing changes alter pitching statistics and control of those receiving repair with internal bracing.

4.1

4.1 Limitations

It is important to note the limitations this study contains. Some of the included sources, specifically involving the docking technique, presented modifications relating to the strandedness and thickness of the graft. For example, one study utilized a quadruple-stranded graft for the docking technique instead of a double-stranded graft,²⁹ and another study incorporated the excess graft into the reconstruction instead of cutting it.⁶ Although, through an initial review, it does not appear differences in graft choice impacts return to the same level of play.⁴⁰ Additionally, some sources did not specify what return to competition entailed and whether it was to the prior-injury level or higher, thus limiting the amount of data included for both rates and times to return to the same level of competition or higher. Return to the same level of play or higher also could have been impacted by factors beyond the surgical outcome, as some athletes personally chose not to further pursue athletic activity,¹⁵^,¹⁶ had other medical diagnoses,¹⁵ or were treated close to graduation with no plans to play at the next level.²⁶^,¹⁶ Bias amongst reviewed articles was also minimally appreciated due to the limited amount of data regarding the surgical techniques.

5 Conclusion

Repair with internal bracing presented a statistically significant higher return to play rate to the same level of competition or higher than both reconstruction techniques included. The docking technique presented a statistically significant lower minor postoperative complication rate than modified Jobe and repair with internal bracing techniques. The modified Jobe technique presented a statistically lower major postoperative complication rate than the repair with internal bracing technique.

Practical implications

•Ulnar collateral ligament repair using an internal brace provides high return to play rates to the same level or higher than the reconstruction techniques analyzed•The docking technique presented a statistically significant lower minor postoperative complication rate than both the modified Jobe and repair with internal bracing techniques.•The modified Jobe reconstruction technique resulted in smaller return rates to the operating room following surgery than the repair with internal bracing technique.•More data surrounding these surgical techniques can provide better insight into outcomes and return to play rates.

CRediT authorship contribution statement

Ben Nagy: Data curation, Formal analysis, and interpretation, Writing – original draft, preparation, Writing – review & editing. Jacob Alexander: Data curation, Formal analysis, and interpretation, Writing – original draft. Jiayong Liu: Conceptualization, Methodology, Software, Formal analysis, and interpretation, Writing – review & editing, Supervision.

Confirmation of ethical compliance

We hereby confirm that this manuscript adheres to ethical standards in research and publication.1.Ethical Approval: This study was conducted in accordance with ethical guidelines.2.Informed Consent: Written informed consent was not applicable.3.Confidentiality: We have taken all necessary measures to ensure the confidentiality and anonymity of the participants throughout the research process.4.Conflict of Interest: The authors declare no conflicts of interest related to this manuscript.5.Data Integrity: All data reported in this manuscript are accurate and have not been fabricated or manipulated in any way.

Funding information

This research was conducted independently and did not receive specific funding from public, commercial, or not-for-profit agencies.

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Introduction

Methods

Results

Discussion

Limitations

Conclusion

Practical implications

CRediT authorship contribution statement

Guardian/patient's consent

Confirmation of ethical compliance

Funding information

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[1] Jobe F.W., Stark H., Lombardo S.J., . Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986;68(8):1158-1163.
[Google Scholar]

[2] Azar F.M., Andrews J.R., Wilk K.E., Groh D., . Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28(1):16-23.
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A systematic review of surgical outcomes of ulnar collateral ligament rupture in the elbow treated with various techniques

Abstract