Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review.

BACKGROUND: Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated. PURPOSE/HYPOTHESIS: The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs. RESULTS: Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%. CONCLUSION: This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.

Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS: There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS: Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION: Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.

Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. PURPOSE: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. RESULTS: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. CONCLUSION: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Long-Term Sports Participation and Satisfaction After UCL Reconstruction in Amateur Baseball Players.

BACKGROUND: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. PURPOSE: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We evaluated UCLR patients who were nonprofessional baseball athletes aged <25 years at a minimum of 5 years postoperatively. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), the Timmerman-Andrews (T-A) Elbow score, the Mayo Elbow Performance Score (MEPS), and a custom return-to-play questionnaire. RESULTS: A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. CONCLUSION: In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.