Paper 20: Clinical Outcomes of Ulnar Collateral Ligament Repair with Internal Brace Versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes
Authors: Dugas Jeffrey , Froom Ryan , Mussell Eric , Carlson Sydney , Tulowitzky Graham , Dias Travis , Patel Arsh , Kidwell-Chandler Ariel , Ithurburn Matthew , Ryan Michael , Rothermich Marcus , Emblom Benton , Cain E. Lyle 
Published: August 2024

Objectives:

The prevalence of ulnar collateral ligament (UCL) injuries and their surgical treatment has risen significantly since the first treated by Dr. Jobe in 1974. The recent surgery, primarily amongst 15- to 25-year-olds involved in overhead sports, is concerning and necessitates refinement of and/or development of the most effective treatment options. The traditional surgical treatment has been UCL reconstruction, but more recently, the development of UCL repair techniques, particularly with the use of internal bracing, are an exciting potential alternative. Whereas previous work has examined early complications and early outcomes following UCL repair with internal brace, to our knowledge, few if any previous studies have compared mid-term outcomes between UCL repair and UCL reconstruction. Our study aimed to examine differences in mid-term outcomes between competitive athletes following UCL repair with internal brace or following UCL reconstruction from a single institution. Specifically, we compared patient-reported elbow and upper extremity function measures and return to preinjury sport between treatment groups.

Methods:

Using CPT codes from an ongoing prospective data repository, we performed a retrospective search to identify patients that underwent either UCL repair with internal brace or UCL reconstruction between 2013 and 2021. We included those 15 to 45 years old that were at least 2-years post-operative and were competitive athletes at time of surgery. We excluded those with prior index elbow surgery, those with UCL repair without internal bracing. We performed detailed chart reviews using the electronic medical record and collected demographic information, injury data, and surgical details. We assessed patient-reported outcomes at follow-up using the following measures of elbow/upper extremity function: 1) American Shoulder and Elbow Surgeons Elbow assessment form (ASES-E; function subscale); 2) Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score (KJOC); 3) Andrews-Carson score. We further collected information on return-to-sport timing and success. We calculated summary statistics for demographic, injury, surgical, and outcomes data within both the UCL repair and reconstruction groups. We compared key demographic, injury, and surgical data between UCL repair and reconstruction groups using independent t-tests for continuous variables and chi-square tests for categorical data. For outcomes data, we used linear regression modeling (controlling for relevant demographic covariates) to compare patient-reported function measures (ASES-E; KJOC; Andrews-Carson) between groups. Lastly, we summarized return to preinjury sport (and reasons for the inability to return) and compared the proportions of successful return to preinjury sport between groups using a chi-square test.

Results:

Clinical and outcomes data were successfully collected for 411 athletes with UCL injuries and surgical treatment (mean age at surgery=18.9±2.9 years; 93% male; mean follow-up time=4.9±2.2 years). Of the 411 UCL procedures, 265 (64%) were UCL repair with internal brace, and 146 (36%) were UCL reconstructions. The UCL repair group was younger (p=0.04), had shorter follow-up time (p<0.01), and had a higher proportion of females (p=0.02) when compared with the UCL reconstruction group (Table 1). Table 1 also shows primary sport at time of UCL injury and level of competition within both groups. Within the UCL repair group, there was a higher proportion of partial UCL tears and a lower proportion of complete UCL tears when compared with the UCL reconstruction group (p<0.01; Table 1). Additionally, within the UCL repair group, there was a lower proportion of concomitant ulnar nerve transpositions when compared with the UCL reconstruction group (p<0.01; Table 1). There were no differences between groups in the proportions of concomitant osteophyte excisions (Table 1). Outcomes-related data are shown in Table 2. Because of differences between groups in age and follow-up time, we controlled for these in comparisons of patient-reported outcomes between groups. After controlling for age and follow-up time, the groups did not differ in ASES-E, KJOC, nor Andrews-Carson scores at follow-up (Table 2). Of the 265 athletes in the repair group, 244 attempted to return to their preinjury sport (Table 2). Among the 244 that attempted to return, 237 (97%) were able to return to their preinjury sport, and 7 were unable to return due to limitations from their UCL repair (Table 2). Of the 146 athletes in the reconstruction group, 140 attempted to return to their preinjury sport (Table 2). Among the 140 that attempted to return, 137 (98%) were able to return to their preinjury sport, and 3 were unable to return due to limitations from their UCL reconstruction (Table 2). Other reasons for not attempting to return to preinjury sport within the 2 groups are shown in Table 2. The two groups did not statistically differ in the proportions that returned to preinjury sport (Table 2).

Conclusions:

In the current study, we found excellent elbow function and return-to-sport mid-term outcomes in a large cohort of both UCL repairs with internal brace and UCL reconstructions. Whereas the groups did differ in some demographic, injury, and concomitant surgical procedure variables, they did not differ in patient-reported outcomes nor in the ability to return to preinjury sport. These findings suggest that UCL repair with internal brace may be a viable option for the treatment of UCL injuries when clinically-indicated. Given the observational and retrospective nature of the current study, future research should evaluate randomized surgical intervention of UCL injuries.