Bowman Eric N, Smith Matthew V, Freehill Michael T, Camp Christopher L, Erickson Brandon J, Sciascia Aaron, Da Silva Adrik, Chalmers Peter N
Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA.
Washington University in St. Louis, Chesterfield, MO, USA.
J Shoulder Elbow Surg. 2023 May;32(5):1066-1073. doi: 10.1016/j.jse.2023.01.001. Epub 2023 Feb 2.
Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction.
Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries.
The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P < .001). Significant indications for repair included distal partial (OR = 1.6, 95% CI 1.0, 2.1, P < .001) and full-thickness tears (OR = 1.7, 95% CI 1.1, 2.3, P < .001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR = 3.0, 95% CI -5.0, -1.0, P = .004). Ultrasound stress testing was requested in 78% of partial tears.
Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.
尺侧副韧带（UCL）撕裂在棒球运动员中很常见。当非手术治疗失败时，可能需要进行重建或修复以恢复身体功能。基于磁共振成像（MRI）撕裂特征的手术适应症或选择修复而非重建的适应症尚无明确共识。本研究的目的是根据MRI确定UCL手术的适应症，并阐明UCL修复与重建的适应症。
对26名治疗棒球运动员的骨科医生进行了调查。回顾了45份MRI：15份无UCL撕裂，15份术中证实为部分厚度撕裂，15份为全层撕裂。研究的因素包括韧带特征（韧带周围或骨水肿、韧带肥大、钙化、部分或全层撕裂）和位置（近端、中部或远端）。给外科医生一个临床病例，询问他们1）是否需要手术，2）是否推荐修复或重建。优势比（OR）和95%置信区间（95%CI）有助于确定两个问题的显著预测因素。
与非手术治疗相比，推荐手术治疗的几率在近端部分厚度撕裂时高2.4倍，远端部分厚度撕裂时高3.2倍，远端全层撕裂时高5.1倍，近端全层撕裂时高7.0倍（P <.001）。修复的显著适应症包括远端部分（OR = 1.6，95%CI 1.0，2.1，P <.001）和全层撕裂（OR = 1.7，95%CI 1.1，2.3，P <.001）。对于中部全层撕裂推荐修复的可能性降低3倍（OR = 3.0，95%CI -5.0，-1.0，P =.004）。78%的部分撕裂患者进行了超声应力测试。
在接受调查的外科医生中，推荐手术治疗几率最高的是近端全层撕裂，其次是远端全层、远端部分厚度和近端部分厚度撕裂。修复最适合于远端部分和全层撕裂，但相对禁忌用于中部UCL完全撕裂。部分撕裂经常需要进行超声应力测试。鉴于外科医生之间缺乏共识，未来需要前瞻性登记来确定这些因素是否与临床结果相关。
