Hintz, Christian

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback for throwing athletes, often requiring reconstruction with 12 to 18 months of rehabilitation. The authors previously described a more anatomic technique with improved mechanical strength as compared with the docking technique, which may allow for an accelerated return to sport. Purpose: To evaluate return-to-sport rates, time to return to sport, and the effect on the functional performance of amateur and professional throwing athletes who underwent anatomic MUCL reconstruction with suture tape augmentation. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series was performed including baseball players who underwent anatomic MUCL reconstruction with suture tape augmentation by a single surgeon from 2018 to 2022. Inclusion criteria consisted of a minimum 2-year follow-up, participation in baseball, and utilization of autograft (palmaris longus or gracilis). Patients who underwent previous MUCL reconstruction were excluded from the study. All patients initially followed an accelerated rehabilitation protocol. Outcome measures were collected, including Kerlan-Jobe Orthopaedic Clinic (KJOC), Single Assessment Numeric Evaluation (SANE), and Conway-Jobe scores, as well as throwing metrics such as ball velocity and spin rate. Results: Thirty-four baseball players (mean ± SD age, 21 ± 3 years) underwent primary MUCL reconstruction. Time of final follow-up was 36.1 ± 10.3 months. Of these, 16 were professional athletes and 18 were amateur. All throwers returned to live gameplay at a mean 10.1 ± 2.0 months after reconstruction (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8). Furthermore, 97% (94% professional, 100% amateur) advanced through the accelerated postoperative protocol without issues, and 91% (88% professional, 94% amateur) returned to the same role and 85% (75% professional, 94% amateur) to the same level of play. Professional postinjury KJOC scores improved from 42.6 ± 16 to 87.5 ± 8.3 and SANE scores from 25.0 ± 11.2 to 95.6 ± 4.2. Amateur postinjury KJOC scores improved from 35.6 ± 10.7 to 90.9 ± 8.6 and SANE scores from 57.5 ± 16.9 to 95.2 ± 7.2. No significant difference was identified in preinjury versus postreconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. The overall failure rate was 2.9%, with 1 professional pitcher requiring revision for graft rupture at 3 years postoperatively. Conclusion: Anatomic reconstruction of the MUCL with suture tape is a viable option for MUCL injuries, allowing an expedited return to sport at 10.1 ± 2.0 months (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8) in baseball players, with a low failure rate.

Objectives: Injury to the Medial Ulnar Collateral Ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12-18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL which may contribute to the prolonged course of rehabilitation. In recent years, we described an anatomic MUCL reconstruction with internal brace augmentation which demonstrated improved biomechanical strength when compared to the docking technique in cadaveric specimens. The purpose of this study was to evaluate the postoperative course of both amateur and professional throwing athletes that underwent anatomic MUCL reconstruction with internal brace augmentation. We hypothesized that throwers would return to the same level of play and that return to play (RTP) would be a shorter duration compared to current reported outcomes. Methods: In this surgical technique, the native MUCL is formally repaired. The graft and a suture tape are folded over a suspensory loop and secured in a socket of the medial epicondyle of the humerus to maximize tendon to bone contact. On the ulnar side, the graft and internal brace are secured proximally by two suture anchors on either side of the sublime tubercle and further secured across the sublime tubercle ridge distally to re-create the anatomic triangular insertion of the native ligament. All surgeries were performed by a single surgeon. Patient reported outcomes in addition to date of RTP, level of play, and functional outcomes were retrospectively gathered. All patients initially followed an Accelerated Rehabilitation Protocol and were converted to a Standard Paced protocol if setbacks were encountered. Results: A total of 26 baseball players underwent primary (n=23) or revision (n=3) MUCL reconstruction with the Anatomic Technique. Of these, 15 were professional and 11 were amateur athletes. 92% of throwers returned to play at a mean of 9.9 months following reconstruction. 89% were able to advance through the accelerated postoperative protocol without issues and 85% returned to the same role and level of play. Post injury KJOC scores improved from 41 to 86.9 and SANE scores improved from 32.5 to 95.5. No significant difference was identified in pre-injury versus post-reconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. Conclusions: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries. Advantages include increased tendon-bone contact of the reconstruction, multiple fixation points, and anatomic restoration of the MUCL. This technique allowed an expedited return to sport for these baseball athletes.

Purpose To analyze the current literature regarding risk factors associated with medial ulnar collateral ligament (MUCL) injury in baseball players and to serve as a robust source for identifying modifiable risk factors that once optimized, have the potential to reduce injury risk. Methods Comprehensive search of the available literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Studies were included if they evaluated risk factors for MUCL injuries in the elbow of baseball players. Risk of bias assessment was performed via Methodological Index for Non‐randomized Studies (MINORS) scoring system. The Oxford Centre for Evidence‐Based Medicine was used to determine level of evidence. Variables of interest; player age, position, shoulder motion, humeral retrotorsion, joint laxity, strength, balance, geography, velocity, pitch count, pitch types, throwing volumes, and throwing mechanics were recorded. Results Twenty‐one studies were included in this systematic review. MINORS scores ranged from 75 to 87%, and variables demonstrated significant heterogeneity. Performance‐based risk factors for MUCL injury included: increased pitch count (both annual and per game), higher percentage of fastballs thrown, smaller pitch repertoire, and/or a loss of pitching velocity. Biomechanical studies demonstrated the relationship between decreased shoulder range of motion (total ROM, ER, IR, and abduction), increased humeral retrotorsion, increased elbow valgus opening in the throwing arm, lower Y‐Balance score, and increased lateral release position to increased MUCL injury. Conclusions Risk factors for MUCL injury can generally be categorized into 4 primary groups: 1) various player demographics and characteristics, 2) throwing too hard (high velocity), 3) throwing too much (pitch count/volume), and 4) throwing with poor mechanics. In this systematic review, the most significant nonmodifiable risk factors for MUCL injuries included: increased glenohumeral retrotorsion and elbow valgus opening. The most consistent modifiable risk factors included: total shoulder range of motion, pitch count, pitch selection, Y balance score, and lateral release position. Pitch velocity was inconsistent in literature, but most studies found this as a risk for injury. These risk factors may serve as appropriate targets for future evidence‐based injury mitigation strategies. Level of Evidence Level IV, systematic review of Level II‐IV studies.