Ulnar Collateral Ligament (UCL) Reconstruction

Overuse injuries to the elbow in the throwing athlete are frequent. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on athletes from all levels of competition.

The purpose of this study is to review all ulnar collateral ligament reconstructions performed at a single institution between January 2004 – July 2014. The study reported patient demographics, clinical outcomes, return to sport rate and complications.

1. Ulnar Collateral Ligament Reconstruction: The Rush Experience Brandon J. Erickson MD, Bernard R. Bach Jr. MD , Mark S Cohen, Charles A. Bush- Joseph MD, Brian J. Cole, Nikhil N. Verma, Gregory P. Nicholson, and Anthony A. Romeo MD

2. Disclosures No relevant disclosures. Funding sources: KFx Medical AANA Accelerated Rehabilitation Centers Ltd. MAOA

3. DISCLOSURES I have no conflicts of interest to report Conflicts from co-authors: Dr. Bach: American Orthopaedic Society for Sports Medicine: Board or committee member, Arthrex , Inc : Research support, CONMED Linvatec : Research support, DJ Orthopaedics: Research support, Ossur : Research support, SLACK Incorporated: Publishing royalties, financial or material support, Smith & Nephew: Research support, Tornier : Research support Dr. Cohen: Acumed, LLC: Paid consultant, Integra : IP royalties; Paid consultant Dr. Bush-Joseph : American Journal of Sports Medicine: Editorial or governing board Dr. Cole: Aesculap / B.Braun : Research support, American Journal of Orthopedics: Editorial or governing board, American Orthopaedic Society for Sports Medicine: Board or committee member, American Shoulder and Elbow Surgeons: Board or committee member, Arthrex , Inc : IP royalties; Paid consultant; Research support, Arthroscopy : Editorial or governing board, Arthroscopy Association of North America: Board or committee member, Athletico : Other financial or material support, Carticept : Stock or stock Options, Cytori : Research support, DJ Orthopaedics: IP royalties, Elsevier Publishing: IP royalties, International Cartilage Repair Society: Board or committee member, Journal of Bone and Joint Surgery - American: Editorial or governing board, Journal of Shoulder and Elbow Surgery: Editorial or governing board, Journal of the American Academy of Orthopaedic Surgeons: Editorial or governing board, Medipost : Research support, National Institutes of Health (NIAMS & NICHD): Research support, Ossur : Other financial or material support, Regentis : Paid consultant; Stock or stock Options, Saunders /Mosby-Elsevier: Publishing royalties, financial or material support, SLACK Incorporated: Publishing royalties, financial or material support, Smith & Nephew: Other financial or material support, Tornier : Other financial or material support, Zimmer : Paid consultant; Research support

4. DISCLOSURES I have no conflicts of interest to report Conflicts from co-authors: Dr. Verma : Arthrex, Inc : Research support, Arthroscopy : Editorial or governing board; Publishing royalties, financial or material support. Arthroscopy Association Learning Center Committee: Board or committee member, Arthrosurface : Research support, Cymedica : Stock or stock Options, DJ Orthopaedics: Research support Journal of Knee Surgery: Editorial or governing board, Minivasive : Paid consultant; Stock or stock Options, Omeros : Stock or stock Options, SLACK Incorporated: Editorial or governing board Smith & Nephew: IP royalties; Paid consultant, Smith & Nephew, Athletico , ConMed Linvatec , Miomed , Mitek: Research support, Vindico Medical-Orthopedics Hyperguide ,: Publishing royalties, financial or material support Dr. Nicholson: Innomed : IP royalties, SLACK Incorporated: Publishing royalties, financial or material support, Tornier : Paid consultant; Research support, Zimmer : Stock or stock Options Dr. Romeo: American Orthopaedic Society for Sports Medicine: Board or committee member, American Shoulder and Elbow Surgeons: Board or committee member. Arthrex , Inc : IP royalties; Other financial or material support; Paid consultant; Paid presenter or speaker; Research support, DJO Surgical: Research support Orthopedics : Editorial or governing board, Orthopedics Today: Editorial or governing board, Ossur : Research support, SAGE : Editorial or governing board, Saunders /Mosby-Elsevier: Publishing royalties, financial or material support, SLACK Incorporated: Editorial or governing board; Publishing royalties, financial or material support, Smith & Nephew: Research support, Wolters Kluwer Health - Lippincott Williams & Wilkins: Editorial or governing board

5. INTRODUCTION Overuse injuries to the elbow in the throwing athlete are frequent. Ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, is performed on athletes from all levels of competition.

6. PURPOSES Review all UCLR performed at a single institution between January 2004 – July 2014 Report: Patient Demographics Clinical Outcomes Return to Sport Rate Complications

7. HYPOTHESES T here will be a significant increase in the number of UCLR performed over time Return to sports rates would be >80%

8. METHODS S urgical database of a single group practice was reviewed from January 1st 2004 -July 1st 2014 C urrent procedural terminology (CPT) for UCLR, 24346, was used to search the database 187 patients (188 elbows)

9. METHODS Electronic charts were reviewed for all patients to determine: Patient age Sex Hand dominance Presence or absence of pre-op ulnar nerve sx Physical exam findings Prior elbow surgeries Traumatic or atraumatic injury Sport played (if any) Level of sport played (high school, collegiate, professional, recreational) Surgical technique Whether a concomitant arthroscopy and/or ulnar nerve transposition was performed Graft type Complications

10. METHODS Patients with working phone numbers on file who were more than 18 months out from surgery were then contacted by the lead author via phone calls Patients were asked about A bility or inability to return to sport Function on return to sport (same , better, or worse) Any complications they experienced Conway -Jobe score Timmerman & Andrews score Kerlan -Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score

11. RESULTS P=0.0017

12. RESULTS P=0.83

13. RESULTS

14.   Middle School Athlete at time of surgery? High School Athlete at time of surgery? College Athlete at time of surgery? Professional Athlete at time of surgery? Recreational Athlete at time of Surgery Number of 1 68 97 7 15 Patients Results   Baseball Player? (former or current) Pitcher? Non-Pitcher Softball Player? MLB Player? Volleyball Player? Football Player? Gymnast? Number of 165 155 10 4 7 2 6 4 Patients

15. Results Graft Choice Ipsilateral Palmaris Autograft Contralateral Palmaris Autograft Hamstring Autograft Triceps Autograft Palmaris Allograft Hamstring Allograft Number of Patients 111 2 48 2 2 24 Yes No Ulnar Nerve Transposed? 79 108

16. Results Sport Return to Previous Level? Andrews & Timmerman KJOC Baseball 94.70% 92.8 +/- 6.8 90.8 +/- 5.8 Baseball Pitcher 92.10% 92.8 +/- 6.8 90.5 +/- 5.8 Baseball Non-Pitcher 100% 95 +/- 7.1 94.5 +/- 2.1 Softball 100% 95 +/- 7.1 90.7 +/- 0.9 Gymnastics 50% 87.5 +/- 3.5 76.3 +/- 24.5 Football 100% 100 92 Cheerleader 100% 85 94.7

17. Complications 5.3% (10/187) of patients underwent subsequent surgeries Removal of the cortical fixation button (1 patient) Subsequent ulnar nerve transposition ( 7 patients ) Elbow arthroscopy for loss of motion (1 patient) Revision UCLR (1 patient)

18. LIMITATIONS No pre-operative scores KJOC score is not validated for phone use yet Could not contact all patients for outcome data No physical exam was performed (ROM, strength, etc.)

19. CONCLUSIONS UCLR was performed most commonly on collegiate athletes using an ipsilateral palmaris longus graft Both the standard and double docking techniques are viable surgical techniques when performing an UCLR Overall 94.1% of patients who underwent UCLR were able to return to sport with an average KJOC score of 90.4 and Timmerman Andrews Score of 92.5