Variation in the Rate of Surgery for Ulnar Collateral Ligament Injury of the Metacarpophalangeal Joint of the Thumb.
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ABSTRACT: Background
The indications for repair of rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MP) joint of the thumb are debated. We studied factors predictive of operative treatment.Methods
In this retrospective study, we queried the research database from 3 affiliated urban hospitals in a single city in the United States and identified 383 patients with a thumb MP UCL injury. We recorded age, sex, treating surgeon, and whether or not a magnetic resonance imaging (MRI) was ordered. If radiographs showed a concomitant avulsion fracture, we measured fragment size and displacement. Multivariable logistic regression was used to identify factors independently associated with surgery.Results
Surgery was independently associated with older patient age, widely displaced fractures (≥2 mm), and obtaining an MRI. Two specific surgeons were less likely to operate. Compared with patients without a fracture, fractures without displacement were less likely to have surgery.Conclusions
The rate of surgery for acute thumb MP UCL injury varies based on patient characteristics and the individual treating surgeon. Variation might decrease with improved diagnostic techniques and consideration of practice guidelines. Future studies are needed to determine the patients and injuries that will benefit most from surgery.
SUBMITTER: Stoop N
PROVIDER: S-EPMC5684936 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Injury to the ulnar collateral ligament of the thumb is very common and can be disabling when missed or left untreated. We present a review of literature and our preferred way of management.
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Project description:BackgroundThe clinical diagnosis of thumb ulnar collateral ligament disruption has been based on joint angulation during valgus stress testing. This report describes a definitive method of distinguishing between complete and partial ulnar collateral ligament injuries by quantifying translation of the proximal phalanx on the metacarpal head during valgus stress testing.MethodsSixty-two cadaveric thumbs underwent standardized valgus stress testing under fluoroscopy with the ulnar collateral ligament intact, following an isolated release of the proper ulnar collateral ligament, and following a combined release of both the proper and the accessory ulnar collateral ligament (complete ulnar collateral ligament release). Following complete ulnar collateral ligament release, the final thirty-seven thumbs were also analyzed after the application of a valgus force sufficient to cause 45° of valgus angulation at the metacarpophalangeal joint to model more severe soft-tissue injury. Two independent reviewers measured coronal plane joint angulation (in degrees), ulnar joint line gap formation (in millimeters), and radial translation of the proximal phalanx on the metacarpal head (in millimeters) on digital fluoroscopic images that had been randomized.ResultsCoronal angulation across the stressed metacarpophalangeal joint progressively increased through the stages of the testing protocol: ulnar collateral ligament intact (average [and standard deviation], 20° ± 8.1°), release of the proper ulnar collateral ligament (average, 23° ± 8.3°), and complete ulnar collateral ligament release (average, 30° ± 8.9°) (p < 0.01 for each comparison). Similarly, gap formation increased from the measurement in the intact state (5.1 ± 1.3 mm), to that following proper ulnar collateral ligament release (5.7 ± 1.5 mm), to that following complete ulnar collateral ligament release (7.2 ± 1.5 mm) (p < 0.01 for each comparison). Radial translation of the proximal phalanx on the metacarpal head did not increase after isolated release of the proper ulnar collateral ligament (1.6 ± 0.8 mm vs. 1.5 ± 0.9 mm in the intact state). There was a significant increase in translation following release of the complete ulnar collateral ligament complex (3.0 ± 0.9 mm; p < 0.01) and an additional increase after forcible angulation of the joint to 45° (4.1 ± 0.9 mm; p < 0.01). Translation 2 mm greater than that in the stressed control was 100% specific for complete disruption of the ulnar collateral ligament complex.ConclusionsWhile transection of the proper ulnar collateral ligament leads to an increase in metacarpophalangeal joint angulation and gapping on stress fluoroscopic evaluation, only release of both the accessory and the proper ulnar collateral ligament significantly increases translation of the proximal phalanx on the metacarpal head.
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Project description:Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.
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Project description:Ulnar collateral ligament (UCL) injuries commonly occur in overhead athletes as a result of excess valgus stress on the elbow and can be functionally debilitating, requiring surgical intervention. Since the advent of the first initial UCL reconstruction technique pioneered by Dr. Frank Jobe performed on professional baseball player Tommy John, UCL, or Tommy John Ligament reconstruction has successfully returned athletes to sport following injury and shown enhanced clinical outcomes with minimal complication rates. Tommy John surgery continues to evolve with the development of various techniques over recent years. This technical note describes a UCL repair with an internal brace using knotless suture anchors and aims to contribute to the current literature a technique that is efficacious and reproducible and offers satisfactory stability, functionality, and return to play.
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Project description:Purpose and hypothesisAlthough sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL.MethodsThis study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis.ResultsIn total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9-90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site.ConclusionsThe results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.
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Project description:IntroductionPlatelet-rich plasma (PRP) has been shown to be effective in treating partial tears of the ulnar collateral ligament (UCL) of the elbow in overhead throwing athletes, but it is still unknown whether it has a role in complete tears. The aim of this study was to assess the effectiveness of PRP in treating complete as well as partial UCL tears. We hypothesized that trephination of the injured UCL followed by injection with PRP can promote healing of both partial and complete tears.MethodsThirty-four baseball players with partial or complete UCL tears confirmed by magnetic resonance imaging (MRI) were included in the study. They were all recalcitrant to more than two months of rest and physical therapy. Under ultrasound guidance, trephination of the UCL was performed using an 18-gauge needle, followed by PRP injection. Visual analog scale (VAS) scores, Disabilities of the Arm, Shoulder, and Hand (DASH) sports module scores, and sonographic ulnohumeral joint space measurements with valgus stress were all obtained prior to the procedure and six months after.ResultsTwenty-six of 30 athletes were able to return to sport with pre-injury level of play within six months after the procedure, at an average time of 12.4 weeks (range: 10-18). Four subjects needed surgical treatment for persistent UCL insufficiency. The average follow-up was 54.2 weeks (range: 26-148). The average VAS and DASH scores improved from 53.5 to 17.2 (p < 0.0001) and from 81.7 to 24.2 (p < 0.0001), respectively. The average ulnohumeral joint space opening with valgus stress decreased from 3.81 mm to 3.45 mm (p = 0.018). Subgroup analysis by injury location revealed that the average VAS score improved from 48.2 to 8.6 (p < 0.0001) and from 64.0 to 34.5 (p = 0.0023) in proximal and distal tears, respectively. The average DASH score improved from 83.8 to 17.8 (p = 0.0001) and from 77.5 to 36.7 (p < 0.0001) in proximal and distal tears, respectively. The average ulnohumeral joint space opening with valgus stress decreased from 3.64 to 3.21 mm (p = 0.003) and from 4.14 to 3.92 mm (p = 0.0023) in proximal and distal tears, respectively. There was one case with a proximal tear that needed surgical management for failure of treatment, while there were three cases needing surgery in those with distal tears.ConclusionUltrasound-guided PRP injection following trephination can be an effective treatment option for both partial and complete UCL tears of the elbow, especially proximal tears. The use of this technique for complete UCL tears may allow more athletes to avoid surgery and enable them to return to play faster.
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Project description:OBJECTIVE:Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non-professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non-professional athletes and in non-sport-related trauma patients with MUCL lesions. METHODS:A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were "ulnar collateral ligament injury," "elbow," "surgery," and "conservative treatment". Patients were divided into three groups: patients who underwent conservative treatment (C-group), surgical treatment (S-group), and surgery after a failed conservative treatment (C&S-group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan-Jobe Orthopaedic Clinic score (KJOC). RESULTS:A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C-group had better results. Excellent results were found in 98.8% of the C-group, in 88.1% of the S-group, and in 87.7% of the C&S-group. The complication rate in the C-group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction. CONCLUSIONS:There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.
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