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Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population
ARTICLE IN PRESS J Shoulder Elbow Surg (2017) ■■, ■■–■■
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population Marina J. Rodriguez, MDa,*, Nicholas A. Kusnezov, MDa, John C. Dunn, MDa, Brian R. Waterman, MDa,b, Kelly G. Kilcoyne, MDa a
Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
b
Hypothesis: The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. Methods: All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. Results: We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. Conclusion: Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%. Level of evidence: Level IV; Case Series; Treatment Study Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral ulnar collateral ligament; posterolateral rotatory instability; functional outcomes; elbow instability; reconstruction; return to activity
Institutional review board approval: William Beaumont Army Medical Center IRB (protocol No. 399155). *Reprint requests: Marina J. Rodriguez, MD, Department of Orthopaedic
Surgery and Rehabilitation, William Beaumont Army Medical Center, 5005 N Piedras St, El Paso, TX 79920, USA. E-mail address: [email protected] (M.J. Rodriguez).
1058-2746/$ - see front matter Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees. https://doi.org/10.1016/j.jse.2017.08.015
ARTICLE IN PRESS 2 In 1991, O’Driscoll et al15 described posterolateral rotatory instability (PLRI) as the clinical condition resulting from insufficiency of the lateral ulnar collateral ligament (LUCL). As the primary stabilizer against varus stress, the LUCL is responsible for maintaining reduction of the radiocapitellar and ulnohumeral joints, particularly under axial load with the forearm in supination.1-4,11-13 Consequently, partial or complete disruptions of the LUCL often result in symptomatic radiocapitellar joint subluxation and may impair participation in sports or other load-bearing upper extremity activity.10,14 When injured, the LUCL may be repaired primarily if the injury is acutely identified and good-quality ligament is available.17 However, most patients present with chronic— sometimes occult—instability and are managed most reliably with ligamentous reconstruction after failure of conservative approaches, although arthroscopic repair may also be used.1,7 There is limited literature evaluating functional outcomes following LUCL reconstruction.6,9,10,16,17 Furthermore, the ability to return to preinjury levels of activity, especially in a young athletic population who might typically sustain these injuries, remains unknown. The purpose of this investigation was to characterize the functional and surgical outcomes following LUCL reconstruction for PLRI in a homogenously active military cohort with intense and unique upper extremity demands. The hypothesis was that LUCL reconstruction would offer active military patients restoration of elbow stability allowing them to stay on active duty and return to their previous level of activity.
Methods This is a retrospectively reviewed case series of active-duty military service members undergoing LUCL reconstruction with prospectively collected validated outcome scores. The Military Health System Management Analysis and Reporting Tool (M2) was queried to identify all tri-service (Army, Navy, and Air Force) US military service members who underwent LUCL reconstruction (Current Procedural Terminology [CPT] code 24344) between 2008 and 2013. The dataset generated was then cross-referenced with the Armed Forces Health Longitudinal Technology Application electronic medical record system, and we performed a retrospective chart review of all patients to first confirm the patients’ diagnoses and indicated procedure. Active-duty service members who underwent primary LUCL reconstruction with at least 2 years of follow-up were included. The following exclusion criteria were applied: other military beneficiaries (ie, family members or retired status), patients with prior LUCL reconstruction, and/or patients with insufficient follow-up. We initially identified 44 patients by Current Procedural Terminology code; 21 patients were excluded because of inaccurate procedural coding, concomitant fracture fixation, medial collateral ligament repair or reconstruction, or inadequate follow-up. For patients meeting the inclusion and exclusion criteria, we recorded demographic data (age, sex, race, branch of service, rank, military occupational specialty, body mass index, hand dominance, medical comorbidities, tobacco use, and previous injuries and surgical procedures), injury-related characteristics (laterality, mech-
M.J. Rodriguez et al. anism and timing of injury, concomitant injuries, and symptoms), and surgical variables (time to surgery, primary procedure, graft type, and concomitant procedures), as well as preoperative and postoperative self-reported pain score (0-10) and range of motion (ROM). In addition, the Mayo Elbow Performance Score (MEPS) and the score on the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire were obtained for all patients at final follow-up. All interviews were performed by an independent third-party investigator. For the MEPS system, scores were interpreted under the following framework: a score of 90 points or greater was considered an excellent outcome; 75-89, a good outcome; 60-74, a fair outcome; and less than 60, a poor outcome. For the QuickDASH, a score between 0 and 100 was generated, with 0 being no disability and 100 being completely disabled. Generally, it is accepted that a score less than 30 is considered little to no disability of the limb whereas a score greater than 69 is considered highly limiting.5 The primary outcomes of interest were the ability to return to full preoperative levels of upper extremity activity without restrictions following surgery, as well as the resolution of symptoms. We additionally assessed all complications (superficial or deep surgicalsite infection, flexion contracture, development of cubital tunnel symptoms, and recurrent instability), reoperations, and revision surgical procedures as secondary outcome measures. US military service members are required to maintain a level of physical training that typically exceeds that of the average civilian. Specific standards for medical fitness are delineated in regulations for the Air Force, Army, Navy, and Marine Corps, and these stipulations dictate the stringent physical requirements of all military service members.8 These regulations are specific to each branch of military service but generally require successful completion of semiannual physical fitness testing that may include timed push-ups, situps, and an aerobic event. Service members are also involved in the following at-risk activities: daily aerobic fitness, weight training, tactical field exercises, and periodic combat deployments (for which service members must be able to lift and carry packs weighing >50 lb, as well as other personal gear), in addition to recreational and competitive sporting activities. All military service members with initiation of an elbow-related medical separation after LUCL reconstruction were identified using the electronic medical record for this study. Statistical means and standard deviations were calculated for continuous variables. Frequencies and percentages were recorded for categorical variables. To evaluate the impact of the various independent variables on the continuous outcomes of interest, the 2-sample t test was performed for categorical independent variables and linear regression analysis for continuous independent variables. In addition, for the binary outcome variable for medical separation, logistic analysis was performed. P < .05 was considered statistically significant. All calculations were performed using SAS software (version 9.4; SAS Institute, Cary, NC, USA).
Results Demographic data A total of 23 patients with primary LUCL reconstruction met the inclusion criteria (Table I). The mean age was 31.6 ± 7.2 years (range, 19-46 years), and most patients were men (87%).
Patient No.
Details of 23 patients Injured side
Tobacco use
Previous elbow injury
Previous elbow surgery
Graft source
MEPS/ QuickDASH score
Preoperative/ postoperative ROM, °*
Preoperative/ postoperative pain score
Medical separation
Complication
Follow-up, y
1 2 3
32/M 21/F 29/F
Nondominant Dominant Nondominant
No No No
None None Lateral elbow hematoma evacuation
Palmaris autograft Palmaris autograft Semitendinosus autograft
45/72.7 75/22.7 100/0.80
0 to 135/5 to 135 20 to 140/0 to 130 –10 to 140/0 to 150
5/3 8/0 5/0
Yes No No
None None None
7.6 7.3 6.9
4
46/M
Dominant
No
None None Supracondylar fx and multiple dislocations Multiple subluxations
LUCL repair with suture anchor
85/4.2
0 to 150/0 to 145
3/3
No
SSI, recurrent infection, and osteomyelitis
6.7
5 6
38/M 36/M
Nondominant Nondominant
No Yes
Multiple dislocations Prior dislocation
80/2.3 75/25
0 to 140/0 to 145 0 to 140/0 to 140
6/0 6/3
No Yes
Cubital tunnel None
5.4 5.3
7 8 9
29/M 25/M 41/M
Nondominant Dominant Nondominant
No Yes Yes
None None None
None Diagnostic elbow arthroscopy None None None
Flexor carpi radialis autograft and semitendinosus allograft augmentation Gracilis allograft NR Palmaris autograft Hamstring autograft Semitendinosus allograft
100/0.8 85/13.6 85/20.5
0 to 125/0 to 130 4 to 140/5 to 140 0 to 140/40 to 100†
NR 3/0 NR
No No No
5.1 4.1 3.2
10 11
19/M 25/M
Dominant Nondominant
No No
None None
Palmaris autograft Gracilis allograft
100/0 100/2.3
0 to 145/0 to 140 10 to 105/30 to 140
2/1 0/2
No No
12 13
32/M 24/M
Nondominant Dominant
Yes Yes
None Multiple dislocations and supracondylar fx Prior capitellum fx Prior dislocation
None None Cubital tunnel and contracture None None
ORIF of capitellum fx None
100/3.3 85/11.7
5 to 135/0 to 140 15 to 140/25 to 130
NR 2/0
No Yes
None None
4.8 4.6
14 15
22/M 39/F
Dominant Nondominant
No No
Palmaris autograft Palmaris autograft and semitendinosus allograft augmentation Gracilis allograft Semitendinosus allograft
100/0 85/3.3
5 to 130/30 to 130 20 to 140/20 to 130
0/0 5/5
No No
None None
4.2 4.2
16
32/M
Dominant
Yes
17
32/M
Nondominant
No
18 19 20 21 22 23
32/M 33/M 29/M 30/M 27/M 44/M
Nondominant Nondominant Nondominant Nondominant Dominant Dominant
Yes Yes No No No Yes
Multiple dislocations Prior lateral epicondyle fx Multiple dislocations
Prior fx and dislocation None None None None None None
None Arthroscopy for loose body removal ORIF of coronoid, radial head, and capitellum fx; primary LUCL repair; and arthroscopy for loose body removal None Elbow arthroscopy None None None None Elbow arthroscopy and loose body removal
7.3 7
Gracilis allograft
70/20.8
20 to 140/20 to 135
5/7
No
Cubital tunnel
3.9
Palmaris autograft
70/29.5
10 to 120/0 to 120
5/0
No
None
3.8
Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft
100/0.8 85/3.3 100/1.7 100/0 85/5 65/14.2
–5 to 140/0 to 145 10 to 130/5 to 140 0 to 135/0 to 145 8 to 125/0 to 135 0 to 140/0 to 140 20 to 140/20 to 130
0/0 5/3 5/0 5/0 5/4 5/5
No No No No No Yes
None None None None None None
3 2.6 2.5 2.3 2.3 2.2
F, female; fx, fracture; LUCL, lateral ulnar collateral ligament; M, male; MEPS, Mayo Elbow Performance Score; NR, not reported; ORIF, open reduction internal fixation; QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand; ROM, range of motion; SSI, surgical-site infection. * Flexion-extension. † Prerelease ROM; 25°-130° after release.
ARTICLE IN PRESS
Age, y/sex
Functional outcomes following LUCL reconstruction
Table I
3
ARTICLE IN PRESS 4 The dominant extremity was injured in the minority of cases (39%). Thirty-nine percent of patients reported regular tobacco use.
Injury characteristics The mechanism of injury was most often low energy (91.3%), consisting of ground-level falls (66.7%) and twisting or tractional injuries (33.3%). Over one-half of the injuries (52.2%) were sustained during recreational sporting activities, whereas the remainder occurred during military training (21.7%), routine activities of daily living (17.4%), and high-energy accidents (8.7%). The average time between injury and reconstruction was 19.5 months (range, 0.6-128 months). Most patients (52%) reported both pain and instability on presentation, whereas 26% reported only instability and 22% reported only pain in the absence of instability. Prior dislocation or instability events were reported by 30% of patients whereas an injury without specific instability complaints was reported by 70%, and 35% had undergone at least 1 prior elbow surgery, including elbow arthroscopy (n = 5), fracture fixation (n = 2), and primary LUCL repair (n = 2). A positive pivot shift was documented for 78% of patients, and magnetic resonance imaging studies were obtained to diagnose injury to the LUCL in 74% of patients; the remaining 6 patients were diagnosed based on physical examination findings and plain radiographs that had previously demonstrated posterolateral ulnohumeral dislocation.
Surgical characteristics Fellowship-trained hand and/or sports medicine surgeons performed 78% of the reconstructions, with the remainder performed by general orthopedic surgeons. Autograft was used in 14 cases, allograft in 6 cases, and autograft supplemented with allograft in an additional 2 cases. Autograft consisted most commonly of ipsilateral palmaris longus (n = 13), whereas allograft was exclusively hamstring (n = 8) (Table I). Patients were immobilized for a brief period and then transitioned to a hinged brace for a progressive ROM and strengthening program.
Outcomes At an average final follow-up of 4.6 ± 1.8 years (range, 2.27.6 years), all patients (100%) experienced relief of their instability symptoms, as well as a significant decrease in their pain (average self-reported pain score, 4 ± 2 preoperatively vs 1 ± 2 postoperatively; P < .001), and had achieved a functional arc of motion (average flexion-extension, 121° ± 27°; average prono-supination, 177° ± 7°). Of 23 patients, 19 (83%) were able to return to full preoperative levels of upper extremity function with no activity restrictions, meeting the physical requirements necessary for continued military service. In contrast, 4 patients (17%)
M.J. Rodriguez et al. underwent medical separation; in only 3 of these patients (13%) was this because of elbow disability incompatible with continued service. One patient underwent medical separation because of disability due to traumatic brain injury, although elbow function demonstrated stable recovery. Furthermore, 26% of patients went on to combat deployments postoperatively. In addition to the retrospective parameters, prospective outcome data were obtained for all 23 patients. Overall, 83% of patients reported good to excellent outcomes by the MEPS (mean, 86; range, 45-100), and almost all patients (96%) reported no significant disability by the QuickDASH disability evaluation (mean, 11; range, 0-73).
Complications Postoperatively, 17% of patients experienced complications, with 3 (13%) requiring reoperation, as well as 1 with transient cubital tunnel symptoms managed nonoperatively. In 1 patient, a severe flexion contracture with cubital tunnel symptoms developed, requiring capsular release and ulnar nerve transposition; another also required ulnar nerve transposition for cubital syndrome; and the last required multiple debridements and revision LUCL reconstruction because of postoperative infection.
Statistical analysis Age less than 30 years was associated with a significantly greater MEPS (93 ± 10 vs 80 ± 16, P = .0364). Sex, hand dominance, subspecialty fellowship training, high-energy injury, chronicity at the time of surgery, tobacco use, prior surgical procedures, type of soft-tissue graft, and presence of complications or reoperation were not significantly associated with the rate of elbow-related medical separation, MEPS, or QuickDASH score at the time of final follow-up (P > .05).
Discussion On the basis of a retrospective review of a military-wide database with prospective outcome data, we found that LUCL reconstruction afforded a return to full function in 83% of our patients with intense daily upper extremity demands. A comparable number of patients (83%) reported good to excellent functional outcomes with no significant disability (96%) as measured by the validated functional outcome scores. However, although all patients maintained a functional ROM with minimal postoperative symptomatology, there was a moderate rate of postoperative complications (17%) and reoperation (13%), largely because of ulnar neuritis and arthrofibrosis. Most series of isolated LUCL reconstruction for symptomatic PLRI are small and retrospective in nature.6,9,10,16,17 Rates of good to excellent outcomes have ranged from 50%-100%.6,9,10,16,17 In a small retrospective series, Lee and Teo 9 reviewed 6 patients following isolated LUCL
ARTICLE IN PRESS Functional outcomes following LUCL reconstruction reconstruction; at follow-up, 50% were asymptomatic, without pain and with excellent ROM. Lin et al10 similarly reviewed the functional outcomes of 14 patients who underwent LUCL reconstruction with autograft. At an average 49-month followup, 93% were satisfied with their ultimate outcome and 64% were pain free. The MEPS was excellent in 72% of patients, good in 21%, and fair in 7%. Jones et al6 performed a retrospective review of LUCL reconstruction in 8 patients with symptomatic PLRI and found that, at a mean followup of 7.1 years, 75% of patients were asymptomatic whereas 25% had persistent instability with activities of daily living; however, all patients reported good to excellent outcomes, with a mean MEPS of 87.5. These studies determined that LUCL reconstruction provides patients with reliable outcomes regarding relief of pain and instability symptoms, with Lin et al additionally identifying that the grade of instability negatively affected postoperative functional outcomes. In the largest series, Sanchez-Sotelo et al17 evaluated clinical and functional outcomes following autogenous LUCL reconstruction in 33 patients. They found that 79% of patients reported favorable results according to the MEPS; however, the daily functional demands of the patients were not quantified. Our study has the advantage of evaluating outcomes following LUCL reconstruction in a population with more rigorous daily upper extremity demands. Furthermore, we were able to demonstrate that most of our patients were able to return not only to their daily activities without significant limitation but to their demanding military duties as well. In the only study to address return to preinjury levels of activity, Olsen and Søjbjerg16 evaluated functional outcomes following 18 consecutive cases of LUCL reconstruction. At an average follow-up of 44 months, they reported that 83% of patients were able to return to their preinjury level of activity, although the occupations and activity levels of the population were unspecified. The MEPS was good or excellent in 16 patients (89%) (excellent in 12 and good in 4). Of the patients, 17 (93%) overall were satisfied with their outcomes. Similarly, the MEPS in our series was good to excellent in 83% of patients. The difference in outcomes may be explained by a younger cohort in the study of Olsen and Søjbjerg, as we identified that age younger than 30 years was a significant predictor of improved MEPS (93 ± 10 vs 80 ± 16, P = .0364). Although the average age was similar (30 years vs 33 years), the cohort of Olsen and Søjbjerg included 8 patients aged under 21 years. This subset of younger patients accounted for one-half of their excellent outcomes and may indicate a greater capacity for improvement among this demographic. Furthermore, the activity level of the military is well characterized, as military service members encounter greater and more uniform upper extremity demands. By contrast, the level of preinjury activity or occupational and athletic function was not fully defined by Olsen and Søjbjerg. Complications were infrequent in other comparative series from the civilian literature, with Jones et al6 reporting no com-
5 plications and the studies by Lee and Teo,9 Lin et al,10 and Olsen and Søjbjerg16 each reporting only 1 patient requiring a return to the operating room. Only 1 case (4%) in our investigation required revision LUCL reconstruction because of a deep space graft infection and secondary debridement, whereas all other patients attained stability. Ulnar nerve decompression was the most common subsequent surgery in our study, suggesting that this should be considered at the time of LUCL reconstruction in select cases. Sanchez-Sotelo et al17 demonstrated a similar rate of complications (21.2%) to our study (17%), which given the larger cohorts of these studies likely yields a more accurate representation of the complication profile. Despite these moderate rates of complications, both cohorts demonstrated high rates of good to excellent outcomes and patient satisfaction. We found that age was the only risk factor with a significant impact on functional outcomes. Specifically, age over 30 years portended a significantly lower average MEPS (80 ± 16 vs 93 ± 10, P = .0364). However, the remaining variables did not have an effect on the outcomes of interest. Our study, however, is too underpowered to perform a more robust statistical analysis of risk factors. Lin et al10 identified increasing instability as graded by fluoroscopic stress views with patients under anesthesia to be predictive of poorer functional outcomes. Sanchez-Sotelo et al17 identified improved functional outcome scores for patients with primary symptoms of instability versus pain, reconstruction versus repair, and traumatic versus iatrogenic or idiopathic injury. They found no association between age, sex, hand dominance, or preoperative ROM and functional outcomes. The results in our study are comparable to the limited existing literature but are more generalizable to other patient groups with intensive daily physical requirements, such as manual laborers, weight lifters, and athletes with significant upper extremity demands. Furthermore, the ability of our patients to return to preinjury levels of activity is a reliable metric of upper extremity function given the mandated physical and occupational demands of the military. We did, however, identify 3 patients who were unable to continue on active duty because of limitations in upper extremity function, although only 1 patient was found to report significant disability on the QuickDASH questionnaire. This is likely because of the ability to self-regulate their activity and upper extremity demands once outside of the military, resulting in little to no perceived disability with their daily elbow function. Our investigation also elucidated complications associated with LUCL reconstruction and evaluated several risk factors for adverse outcomes, which have not been previously reported.
Limitations There are a number of limitations of our study. Given the retrospective nature, we are limited to the data contained within the medical record. Surgical procedures were performed by multiple surgeons across multiple centers; therefore, we could
ARTICLE IN PRESS 6
M.J. Rodriguez et al.
not control for surgical technique or volume. However, fellowship training data were available and were included in our study in an attempt to control for this heterogeneity. Given the nature of a military population, frequent changes in duty station, inconsistent follow-up, or completion of service may commonly limit long-term evaluation in many cases. Despite these limitations, prospectively gathered, validated, patientreported functional outcome measures were obtained on all patients, and our study represents one of the largest series focusing solely on outcomes in an athletic population.
Conclusion Similar to previous studies from active populations, the diagnosis and surgical management of isolated LUCL injury are relatively infrequent within the military. Even with its rarity, primary LUCL reconstruction for symptomatic PLRI offers a reliable return to preinjury level of function among individuals with intense upper extremity demands. Approximately 4 of 5 patients returned to their full preinjury level of occupational function, with fewer than 5% of patients reporting rate-limiting significant disability on resuming military duty. However, patients should be carefully counseled that although patient-reported function and symptomatology reliably improve, there is a greater than 15% rate of perioperative complications.
Acknowledgments We acknowledge Julia Bader, PhD, for assistance with statistical analysis.
Disclaimer The views expressed in this manuscript are those of the authors and do not reflect the official policy of the William Beaumont Army Medical Center, the Department of the Army, the Department of Defense, or the US government. All authors were employees of the US government at the time this work was performed. The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Anakwenze OA, Kwon D, O’Donnell E, Levine WN, Ahmad CS. Surgical treatment of posterolateral rotatory instability of the elbow. Arthroscopy 2014;30:866-71. http://dx.doi.org/10.1016/j.arthro .2014.02.029 2. Bonnaig NS, Throckmorton TQ. Repair and reconstruction of the lateral ulnar collateral ligament. Instr Course Lect 2015;64:243-6. 3. Capo JT, Collins C, Beutel BG, Danna NR, Manigrasso M, Uko LA, et al. Three-dimensional analysis of elbow soft tissue footprints and anatomy. J Shoulder Elbow Surg 2014;23:1618-23. http://dx.doi .org/10.1016/j.jse.2014.05.003 4. Cohen MS, Hastings H. Rotatory instability of the elbow. The anatomy and role of the lateral stabilizers. J Bone Joint Surg Am 1997;79:225-33. 5. Hunsaker FG, Coiffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am 2002;84:208-15. http://dx.doi.org/10.2106/00004623-200202000-00007 6. Jones KJ, Dodson CC, Osbahr DC, Parisien RL, Weiland AJ, Altchek DW, et al. The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes. J Shoulder Elbow Surg 2012;21:389-95. http://dx.doi.org/10.1016/j.jse.2011.04.033 7. Kim JW, Yi Y, Kim TK, Kang HJ, Kim JY, Lee JM, et al. Arthroscopic lateral collateral ligament repair. J Bone Joint Surg 2016;98:1268-76. http://dx.doi.org/10.2106/JBJS.15.00811 8. Kusnezov N, Dunn JC, Parada SA, Kilcoyne K, Waterman BR. Clinical outcomes of anatomical total shoulder arthroplasty in a young, active population. Am J Orthop (Belle Mead NJ) 2016;45:E273-82. 9. Lee BP, Teo LH. Surgical reconstruction for posterolateral rotatory instability of the elbow. J Shoulder Elbow Surg 2003;12:476-9. http://dx.doi.org/10.1016/S1058-2746(03)00091-0 10. Lin K, Shen P, Lee C, Pan R, Lin L, Shen HL. Functional outcomes of surgical reconstruction for posterolateral rotatory instability of the elbow. Injury 2012;43:1657-61. http://dx.doi.org/10.1016/j.injury .2012.04.023 11. McAdams TR, Masters GW, Srivastava S. The effect of arthroscopic sectioning of the lateral ligament complex of the elbow on posterolateral rotatory stability. J Shoulder Elbow Surg 2005;14:298-301. http://dx.doi.org/10.1016/j.jse.2004.08.003 12. McKee MD, Schemitsch EH, Sala MJ, O’Driscoll SW. The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg 2003;12:391-6. http://dx.doi.org/ 10.1016/S1058-2746(03)00027-2 13. Mehta JA, Bain GI. Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg 2004;12:405-15. http://dx.doi.org/10.5435/ 00124635-200411000-00005 14. O’Driscoll SW. Classification and evaluation of recurrent instability of the elbow. Clin Orthop Relat Res 2000;(370):34-43. 15. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-6. 16. Olsen BS, Søjbjerg JO. The treatment of recurrent posterolateral instability of the elbow. J Bone Joint Surg Br 2003;85:342-6. http://dx.doi.org/10.1302/0301-620X.85B3.13669 17. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2005;87:54-61. http://dx.doi.org/10.1302/ 0301-620X.87B1.15096
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population Marina J. Rodriguez, MDa,*, Nicholas A. Kusnezov, MDa, John C. Dunn, MDa, Brian R. Waterman, MDa,b, Kelly G. Kilcoyne, MDa a
Department of Orthopaedic Surgery and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
b
Hypothesis: The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. Methods: All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. Results: We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. Conclusion: Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%. Level of evidence: Level IV; Case Series; Treatment Study Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Lateral ulnar collateral ligament; posterolateral rotatory instability; functional outcomes; elbow instability; reconstruction; return to activity
Institutional review board approval: William Beaumont Army Medical Center IRB (protocol No. 399155). *Reprint requests: Marina J. Rodriguez, MD, Department of Orthopaedic
Surgery and Rehabilitation, William Beaumont Army Medical Center, 5005 N Piedras St, El Paso, TX 79920, USA. E-mail address: [email protected] (M.J. Rodriguez).
1058-2746/$ - see front matter Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees. https://doi.org/10.1016/j.jse.2017.08.015
ARTICLE IN PRESS 2 In 1991, O’Driscoll et al15 described posterolateral rotatory instability (PLRI) as the clinical condition resulting from insufficiency of the lateral ulnar collateral ligament (LUCL). As the primary stabilizer against varus stress, the LUCL is responsible for maintaining reduction of the radiocapitellar and ulnohumeral joints, particularly under axial load with the forearm in supination.1-4,11-13 Consequently, partial or complete disruptions of the LUCL often result in symptomatic radiocapitellar joint subluxation and may impair participation in sports or other load-bearing upper extremity activity.10,14 When injured, the LUCL may be repaired primarily if the injury is acutely identified and good-quality ligament is available.17 However, most patients present with chronic— sometimes occult—instability and are managed most reliably with ligamentous reconstruction after failure of conservative approaches, although arthroscopic repair may also be used.1,7 There is limited literature evaluating functional outcomes following LUCL reconstruction.6,9,10,16,17 Furthermore, the ability to return to preinjury levels of activity, especially in a young athletic population who might typically sustain these injuries, remains unknown. The purpose of this investigation was to characterize the functional and surgical outcomes following LUCL reconstruction for PLRI in a homogenously active military cohort with intense and unique upper extremity demands. The hypothesis was that LUCL reconstruction would offer active military patients restoration of elbow stability allowing them to stay on active duty and return to their previous level of activity.
Methods This is a retrospectively reviewed case series of active-duty military service members undergoing LUCL reconstruction with prospectively collected validated outcome scores. The Military Health System Management Analysis and Reporting Tool (M2) was queried to identify all tri-service (Army, Navy, and Air Force) US military service members who underwent LUCL reconstruction (Current Procedural Terminology [CPT] code 24344) between 2008 and 2013. The dataset generated was then cross-referenced with the Armed Forces Health Longitudinal Technology Application electronic medical record system, and we performed a retrospective chart review of all patients to first confirm the patients’ diagnoses and indicated procedure. Active-duty service members who underwent primary LUCL reconstruction with at least 2 years of follow-up were included. The following exclusion criteria were applied: other military beneficiaries (ie, family members or retired status), patients with prior LUCL reconstruction, and/or patients with insufficient follow-up. We initially identified 44 patients by Current Procedural Terminology code; 21 patients were excluded because of inaccurate procedural coding, concomitant fracture fixation, medial collateral ligament repair or reconstruction, or inadequate follow-up. For patients meeting the inclusion and exclusion criteria, we recorded demographic data (age, sex, race, branch of service, rank, military occupational specialty, body mass index, hand dominance, medical comorbidities, tobacco use, and previous injuries and surgical procedures), injury-related characteristics (laterality, mech-
M.J. Rodriguez et al. anism and timing of injury, concomitant injuries, and symptoms), and surgical variables (time to surgery, primary procedure, graft type, and concomitant procedures), as well as preoperative and postoperative self-reported pain score (0-10) and range of motion (ROM). In addition, the Mayo Elbow Performance Score (MEPS) and the score on the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire were obtained for all patients at final follow-up. All interviews were performed by an independent third-party investigator. For the MEPS system, scores were interpreted under the following framework: a score of 90 points or greater was considered an excellent outcome; 75-89, a good outcome; 60-74, a fair outcome; and less than 60, a poor outcome. For the QuickDASH, a score between 0 and 100 was generated, with 0 being no disability and 100 being completely disabled. Generally, it is accepted that a score less than 30 is considered little to no disability of the limb whereas a score greater than 69 is considered highly limiting.5 The primary outcomes of interest were the ability to return to full preoperative levels of upper extremity activity without restrictions following surgery, as well as the resolution of symptoms. We additionally assessed all complications (superficial or deep surgicalsite infection, flexion contracture, development of cubital tunnel symptoms, and recurrent instability), reoperations, and revision surgical procedures as secondary outcome measures. US military service members are required to maintain a level of physical training that typically exceeds that of the average civilian. Specific standards for medical fitness are delineated in regulations for the Air Force, Army, Navy, and Marine Corps, and these stipulations dictate the stringent physical requirements of all military service members.8 These regulations are specific to each branch of military service but generally require successful completion of semiannual physical fitness testing that may include timed push-ups, situps, and an aerobic event. Service members are also involved in the following at-risk activities: daily aerobic fitness, weight training, tactical field exercises, and periodic combat deployments (for which service members must be able to lift and carry packs weighing >50 lb, as well as other personal gear), in addition to recreational and competitive sporting activities. All military service members with initiation of an elbow-related medical separation after LUCL reconstruction were identified using the electronic medical record for this study. Statistical means and standard deviations were calculated for continuous variables. Frequencies and percentages were recorded for categorical variables. To evaluate the impact of the various independent variables on the continuous outcomes of interest, the 2-sample t test was performed for categorical independent variables and linear regression analysis for continuous independent variables. In addition, for the binary outcome variable for medical separation, logistic analysis was performed. P < .05 was considered statistically significant. All calculations were performed using SAS software (version 9.4; SAS Institute, Cary, NC, USA).
Results Demographic data A total of 23 patients with primary LUCL reconstruction met the inclusion criteria (Table I). The mean age was 31.6 ± 7.2 years (range, 19-46 years), and most patients were men (87%).
Patient No.
Details of 23 patients Injured side
Tobacco use
Previous elbow injury
Previous elbow surgery
Graft source
MEPS/ QuickDASH score
Preoperative/ postoperative ROM, °*
Preoperative/ postoperative pain score
Medical separation
Complication
Follow-up, y
1 2 3
32/M 21/F 29/F
Nondominant Dominant Nondominant
No No No
None None Lateral elbow hematoma evacuation
Palmaris autograft Palmaris autograft Semitendinosus autograft
45/72.7 75/22.7 100/0.80
0 to 135/5 to 135 20 to 140/0 to 130 –10 to 140/0 to 150
5/3 8/0 5/0
Yes No No
None None None
7.6 7.3 6.9
4
46/M
Dominant
No
None None Supracondylar fx and multiple dislocations Multiple subluxations
LUCL repair with suture anchor
85/4.2
0 to 150/0 to 145
3/3
No
SSI, recurrent infection, and osteomyelitis
6.7
5 6
38/M 36/M
Nondominant Nondominant
No Yes
Multiple dislocations Prior dislocation
80/2.3 75/25
0 to 140/0 to 145 0 to 140/0 to 140
6/0 6/3
No Yes
Cubital tunnel None
5.4 5.3
7 8 9
29/M 25/M 41/M
Nondominant Dominant Nondominant
No Yes Yes
None None None
None Diagnostic elbow arthroscopy None None None
Flexor carpi radialis autograft and semitendinosus allograft augmentation Gracilis allograft NR Palmaris autograft Hamstring autograft Semitendinosus allograft
100/0.8 85/13.6 85/20.5
0 to 125/0 to 130 4 to 140/5 to 140 0 to 140/40 to 100†
NR 3/0 NR
No No No
5.1 4.1 3.2
10 11
19/M 25/M
Dominant Nondominant
No No
None None
Palmaris autograft Gracilis allograft
100/0 100/2.3
0 to 145/0 to 140 10 to 105/30 to 140
2/1 0/2
No No
12 13
32/M 24/M
Nondominant Dominant
Yes Yes
None Multiple dislocations and supracondylar fx Prior capitellum fx Prior dislocation
None None Cubital tunnel and contracture None None
ORIF of capitellum fx None
100/3.3 85/11.7
5 to 135/0 to 140 15 to 140/25 to 130
NR 2/0
No Yes
None None
4.8 4.6
14 15
22/M 39/F
Dominant Nondominant
No No
Palmaris autograft Palmaris autograft and semitendinosus allograft augmentation Gracilis allograft Semitendinosus allograft
100/0 85/3.3
5 to 130/30 to 130 20 to 140/20 to 130
0/0 5/5
No No
None None
4.2 4.2
16
32/M
Dominant
Yes
17
32/M
Nondominant
No
18 19 20 21 22 23
32/M 33/M 29/M 30/M 27/M 44/M
Nondominant Nondominant Nondominant Nondominant Dominant Dominant
Yes Yes No No No Yes
Multiple dislocations Prior lateral epicondyle fx Multiple dislocations
Prior fx and dislocation None None None None None None
None Arthroscopy for loose body removal ORIF of coronoid, radial head, and capitellum fx; primary LUCL repair; and arthroscopy for loose body removal None Elbow arthroscopy None None None None Elbow arthroscopy and loose body removal
7.3 7
Gracilis allograft
70/20.8
20 to 140/20 to 135
5/7
No
Cubital tunnel
3.9
Palmaris autograft
70/29.5
10 to 120/0 to 120
5/0
No
None
3.8
Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft Palmaris autograft
100/0.8 85/3.3 100/1.7 100/0 85/5 65/14.2
–5 to 140/0 to 145 10 to 130/5 to 140 0 to 135/0 to 145 8 to 125/0 to 135 0 to 140/0 to 140 20 to 140/20 to 130
0/0 5/3 5/0 5/0 5/4 5/5
No No No No No Yes
None None None None None None
3 2.6 2.5 2.3 2.3 2.2
F, female; fx, fracture; LUCL, lateral ulnar collateral ligament; M, male; MEPS, Mayo Elbow Performance Score; NR, not reported; ORIF, open reduction internal fixation; QuickDASH, short version of Disabilities of the Arm, Shoulder and Hand; ROM, range of motion; SSI, surgical-site infection. * Flexion-extension. † Prerelease ROM; 25°-130° after release.
ARTICLE IN PRESS
Age, y/sex
Functional outcomes following LUCL reconstruction
Table I
3
ARTICLE IN PRESS 4 The dominant extremity was injured in the minority of cases (39%). Thirty-nine percent of patients reported regular tobacco use.
Injury characteristics The mechanism of injury was most often low energy (91.3%), consisting of ground-level falls (66.7%) and twisting or tractional injuries (33.3%). Over one-half of the injuries (52.2%) were sustained during recreational sporting activities, whereas the remainder occurred during military training (21.7%), routine activities of daily living (17.4%), and high-energy accidents (8.7%). The average time between injury and reconstruction was 19.5 months (range, 0.6-128 months). Most patients (52%) reported both pain and instability on presentation, whereas 26% reported only instability and 22% reported only pain in the absence of instability. Prior dislocation or instability events were reported by 30% of patients whereas an injury without specific instability complaints was reported by 70%, and 35% had undergone at least 1 prior elbow surgery, including elbow arthroscopy (n = 5), fracture fixation (n = 2), and primary LUCL repair (n = 2). A positive pivot shift was documented for 78% of patients, and magnetic resonance imaging studies were obtained to diagnose injury to the LUCL in 74% of patients; the remaining 6 patients were diagnosed based on physical examination findings and plain radiographs that had previously demonstrated posterolateral ulnohumeral dislocation.
Surgical characteristics Fellowship-trained hand and/or sports medicine surgeons performed 78% of the reconstructions, with the remainder performed by general orthopedic surgeons. Autograft was used in 14 cases, allograft in 6 cases, and autograft supplemented with allograft in an additional 2 cases. Autograft consisted most commonly of ipsilateral palmaris longus (n = 13), whereas allograft was exclusively hamstring (n = 8) (Table I). Patients were immobilized for a brief period and then transitioned to a hinged brace for a progressive ROM and strengthening program.
Outcomes At an average final follow-up of 4.6 ± 1.8 years (range, 2.27.6 years), all patients (100%) experienced relief of their instability symptoms, as well as a significant decrease in their pain (average self-reported pain score, 4 ± 2 preoperatively vs 1 ± 2 postoperatively; P < .001), and had achieved a functional arc of motion (average flexion-extension, 121° ± 27°; average prono-supination, 177° ± 7°). Of 23 patients, 19 (83%) were able to return to full preoperative levels of upper extremity function with no activity restrictions, meeting the physical requirements necessary for continued military service. In contrast, 4 patients (17%)
M.J. Rodriguez et al. underwent medical separation; in only 3 of these patients (13%) was this because of elbow disability incompatible with continued service. One patient underwent medical separation because of disability due to traumatic brain injury, although elbow function demonstrated stable recovery. Furthermore, 26% of patients went on to combat deployments postoperatively. In addition to the retrospective parameters, prospective outcome data were obtained for all 23 patients. Overall, 83% of patients reported good to excellent outcomes by the MEPS (mean, 86; range, 45-100), and almost all patients (96%) reported no significant disability by the QuickDASH disability evaluation (mean, 11; range, 0-73).
Complications Postoperatively, 17% of patients experienced complications, with 3 (13%) requiring reoperation, as well as 1 with transient cubital tunnel symptoms managed nonoperatively. In 1 patient, a severe flexion contracture with cubital tunnel symptoms developed, requiring capsular release and ulnar nerve transposition; another also required ulnar nerve transposition for cubital syndrome; and the last required multiple debridements and revision LUCL reconstruction because of postoperative infection.
Statistical analysis Age less than 30 years was associated with a significantly greater MEPS (93 ± 10 vs 80 ± 16, P = .0364). Sex, hand dominance, subspecialty fellowship training, high-energy injury, chronicity at the time of surgery, tobacco use, prior surgical procedures, type of soft-tissue graft, and presence of complications or reoperation were not significantly associated with the rate of elbow-related medical separation, MEPS, or QuickDASH score at the time of final follow-up (P > .05).
Discussion On the basis of a retrospective review of a military-wide database with prospective outcome data, we found that LUCL reconstruction afforded a return to full function in 83% of our patients with intense daily upper extremity demands. A comparable number of patients (83%) reported good to excellent functional outcomes with no significant disability (96%) as measured by the validated functional outcome scores. However, although all patients maintained a functional ROM with minimal postoperative symptomatology, there was a moderate rate of postoperative complications (17%) and reoperation (13%), largely because of ulnar neuritis and arthrofibrosis. Most series of isolated LUCL reconstruction for symptomatic PLRI are small and retrospective in nature.6,9,10,16,17 Rates of good to excellent outcomes have ranged from 50%-100%.6,9,10,16,17 In a small retrospective series, Lee and Teo 9 reviewed 6 patients following isolated LUCL
ARTICLE IN PRESS Functional outcomes following LUCL reconstruction reconstruction; at follow-up, 50% were asymptomatic, without pain and with excellent ROM. Lin et al10 similarly reviewed the functional outcomes of 14 patients who underwent LUCL reconstruction with autograft. At an average 49-month followup, 93% were satisfied with their ultimate outcome and 64% were pain free. The MEPS was excellent in 72% of patients, good in 21%, and fair in 7%. Jones et al6 performed a retrospective review of LUCL reconstruction in 8 patients with symptomatic PLRI and found that, at a mean followup of 7.1 years, 75% of patients were asymptomatic whereas 25% had persistent instability with activities of daily living; however, all patients reported good to excellent outcomes, with a mean MEPS of 87.5. These studies determined that LUCL reconstruction provides patients with reliable outcomes regarding relief of pain and instability symptoms, with Lin et al additionally identifying that the grade of instability negatively affected postoperative functional outcomes. In the largest series, Sanchez-Sotelo et al17 evaluated clinical and functional outcomes following autogenous LUCL reconstruction in 33 patients. They found that 79% of patients reported favorable results according to the MEPS; however, the daily functional demands of the patients were not quantified. Our study has the advantage of evaluating outcomes following LUCL reconstruction in a population with more rigorous daily upper extremity demands. Furthermore, we were able to demonstrate that most of our patients were able to return not only to their daily activities without significant limitation but to their demanding military duties as well. In the only study to address return to preinjury levels of activity, Olsen and Søjbjerg16 evaluated functional outcomes following 18 consecutive cases of LUCL reconstruction. At an average follow-up of 44 months, they reported that 83% of patients were able to return to their preinjury level of activity, although the occupations and activity levels of the population were unspecified. The MEPS was good or excellent in 16 patients (89%) (excellent in 12 and good in 4). Of the patients, 17 (93%) overall were satisfied with their outcomes. Similarly, the MEPS in our series was good to excellent in 83% of patients. The difference in outcomes may be explained by a younger cohort in the study of Olsen and Søjbjerg, as we identified that age younger than 30 years was a significant predictor of improved MEPS (93 ± 10 vs 80 ± 16, P = .0364). Although the average age was similar (30 years vs 33 years), the cohort of Olsen and Søjbjerg included 8 patients aged under 21 years. This subset of younger patients accounted for one-half of their excellent outcomes and may indicate a greater capacity for improvement among this demographic. Furthermore, the activity level of the military is well characterized, as military service members encounter greater and more uniform upper extremity demands. By contrast, the level of preinjury activity or occupational and athletic function was not fully defined by Olsen and Søjbjerg. Complications were infrequent in other comparative series from the civilian literature, with Jones et al6 reporting no com-
5 plications and the studies by Lee and Teo,9 Lin et al,10 and Olsen and Søjbjerg16 each reporting only 1 patient requiring a return to the operating room. Only 1 case (4%) in our investigation required revision LUCL reconstruction because of a deep space graft infection and secondary debridement, whereas all other patients attained stability. Ulnar nerve decompression was the most common subsequent surgery in our study, suggesting that this should be considered at the time of LUCL reconstruction in select cases. Sanchez-Sotelo et al17 demonstrated a similar rate of complications (21.2%) to our study (17%), which given the larger cohorts of these studies likely yields a more accurate representation of the complication profile. Despite these moderate rates of complications, both cohorts demonstrated high rates of good to excellent outcomes and patient satisfaction. We found that age was the only risk factor with a significant impact on functional outcomes. Specifically, age over 30 years portended a significantly lower average MEPS (80 ± 16 vs 93 ± 10, P = .0364). However, the remaining variables did not have an effect on the outcomes of interest. Our study, however, is too underpowered to perform a more robust statistical analysis of risk factors. Lin et al10 identified increasing instability as graded by fluoroscopic stress views with patients under anesthesia to be predictive of poorer functional outcomes. Sanchez-Sotelo et al17 identified improved functional outcome scores for patients with primary symptoms of instability versus pain, reconstruction versus repair, and traumatic versus iatrogenic or idiopathic injury. They found no association between age, sex, hand dominance, or preoperative ROM and functional outcomes. The results in our study are comparable to the limited existing literature but are more generalizable to other patient groups with intensive daily physical requirements, such as manual laborers, weight lifters, and athletes with significant upper extremity demands. Furthermore, the ability of our patients to return to preinjury levels of activity is a reliable metric of upper extremity function given the mandated physical and occupational demands of the military. We did, however, identify 3 patients who were unable to continue on active duty because of limitations in upper extremity function, although only 1 patient was found to report significant disability on the QuickDASH questionnaire. This is likely because of the ability to self-regulate their activity and upper extremity demands once outside of the military, resulting in little to no perceived disability with their daily elbow function. Our investigation also elucidated complications associated with LUCL reconstruction and evaluated several risk factors for adverse outcomes, which have not been previously reported.
Limitations There are a number of limitations of our study. Given the retrospective nature, we are limited to the data contained within the medical record. Surgical procedures were performed by multiple surgeons across multiple centers; therefore, we could
ARTICLE IN PRESS 6
M.J. Rodriguez et al.
not control for surgical technique or volume. However, fellowship training data were available and were included in our study in an attempt to control for this heterogeneity. Given the nature of a military population, frequent changes in duty station, inconsistent follow-up, or completion of service may commonly limit long-term evaluation in many cases. Despite these limitations, prospectively gathered, validated, patientreported functional outcome measures were obtained on all patients, and our study represents one of the largest series focusing solely on outcomes in an athletic population.
Conclusion Similar to previous studies from active populations, the diagnosis and surgical management of isolated LUCL injury are relatively infrequent within the military. Even with its rarity, primary LUCL reconstruction for symptomatic PLRI offers a reliable return to preinjury level of function among individuals with intense upper extremity demands. Approximately 4 of 5 patients returned to their full preinjury level of occupational function, with fewer than 5% of patients reporting rate-limiting significant disability on resuming military duty. However, patients should be carefully counseled that although patient-reported function and symptomatology reliably improve, there is a greater than 15% rate of perioperative complications.
Acknowledgments We acknowledge Julia Bader, PhD, for assistance with statistical analysis.
Disclaimer The views expressed in this manuscript are those of the authors and do not reflect the official policy of the William Beaumont Army Medical Center, the Department of the Army, the Department of Defense, or the US government. All authors were employees of the US government at the time this work was performed. The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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