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Increasing Rates of UCL Repair Outpace Reconstruction in Isolated Injuries: Review of a Texas Surgical Database

Open AccessPublished:November 08, 2022DOI:https://doi.org/10.1016/j.jseint.2022.10.008

      Background

      The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures is lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010-2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges.

      Methods

      A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection (THCIC) database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology (CPT) billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament (LCL) tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma (PRP) injection were compared. Total patient-level charges were compared across groups.

      Results

      A total of 1,664 patients were included, consisting of 484 UCL repairs and 1,180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N=25) to 2019 (N=315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010-2019 (P<0.001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P=0.05). There were no differences among commonly associated procedures including ulnar nerve surgery (P=0.217), elbow arthroscopy (P=0.092), and PRP injection (P=0.837) with no differences in patient-level charges at any time point (P=0.47)

      Conclusion

      While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

      Keywords

      Ulnar collateral ligament (UCL) injury is one of the most common orthopedic injuries among overhead athletes.
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      Although there has been a shift in the literature paradigm, it is unknown whether there has been a significant shift in practice as well. Previous epidemiological studies examining ulnar collateral ligament surgery have focused only on trends in ulnar collateral ligament reconstruction.
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      • et al.
      Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011.
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      • Arons R.R.
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      The prevalence of ulnar collateral ligament repair remains unknown.
      Additionally, although multiple existing studies have proposed indications for surgical versus conservative treatment, it remains unknown whether there are any differences between the surgical intervention populations.
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      The purpose of this study was to investigate the practice trends for surgical treatment of UCL injuries in the State of Texas between the years 2010 through 2019 with consideration of procedure volume, patient demographics, concomitant surgical procedures, and patient-level charges. We hypothesized that the overall incidence of UCL repair will have increased more significantly than that of UCL reconstruction between 2010 and 2019 in the state of Texas, and that there would be no demographic or charge differences between the two cohorts.

      Methods

      Procedural Volume

      This study is a retrospective cross-sectional analysis of UCL repair, reconstruction, and any associated procedures. Data was obtained through the publicly available Texas Healthcare Information Collection (THCIC) database, which includes deidentified records of all patients discharged from eligible hospitals and ambulatory surgical centers. Since 2010, policy requires all surgical sites to report an operative case summary that includes patient demographic information, diagnostic billing codes, and a standardized list of itemized charges. Other information collected includes surgery center location, categorization of procedural setting, and type of payor for the procedure. Ethical committee approval was not required due to the anonymized nature of the database. While limited to the State of Texas, this database represents a significant population in a more thorough manner than many national databases by including all payor statuses such as self-pay and worker’s compensation. Thus, by not limiting the patient population to those covered by private or federal insurance, this study can provide insight into the comprehensive practice patterns of a large region while simultaneously offering a holistic analysis of patient charges. Of note, both Major League Baseball and Minor League Baseball players are covered by worker’s compensation, as indicated by their respective Uniform Players Contracts (UPC). The presence of this payor source in the database extends the accessible records to include one of the most high-risk patient populations. Overall incidence of UCL surgery was calculated using the 2010 and 2020 decennial census data collected by U.S. Census Bureau.

      Historical Population Change Data (1910-2020). U.S. Census Bureau; 2021:1-3. https://www.census.gov/data/tables/time-series/dec/popchange-data-text.html

      Inclusion criteria were defined using Current Procedural Terminology (CPT) codes as published by the American Medical Association (AMA). CPT codes provide a standardized method for procedural billing in the United States and allow for retrospective analysis of large populations of surgical patients. The THCIC database was queried for patients who received either UCL reconstruction (CPT 24346; N=1255) or repair (CPT 24345; N=514) beginning in 2010 through 2019. Exclusion criteria were defined as the presence of the respective CPT, ICD-9, or ICD-10 codes for post-traumatic indications, such as fracture (CPT 24685, N=18) or lateral collateral ligament (LCL) injury (CPT 24343 and 24344, N=70 and 24, respectively). Changes in procedural frequency were analyzed with weighted linear regression models.

      Demographics, Charges, and Associated Procedures

      Demographic data included patient gender, age (categorized as <18, 18-44, 45-64, and >65 years), and ethnicity. Procedural setting was defined in a categorical manner as either a teaching or non-teaching hospital, depending on membership of the Council of Teaching Hospitals and Health Systems (COTH). Payor status was defined as private insurance, Medicare, Medicaid, worker’s compensation, self-pay, or other. Charges regardless of payor status were compared between repair and reconstruction for the entire timeframe as well as within each individual year. All included records were then analyzed for commonly performed concomitant procedures including surgery of the ulnar nerve (CPT 64718), PRP injection (CPT 0232T), or any arthroscopic procedure of the elbow (CPT 29834, 29837, 29838).

      Literature Query

      Due to a subjective increase in academic interest in UCL repair, a review of literature published during the study period was performed to assess for any temporal correlation between relevant publication frequency and procedural volume. The search was performed on August 26, 2021, using the following two databases: PubMed and Embase. The electronic search engine formula was defined as follows: ((ulnar collateral ligament) AND (repair)). Studies and editorials related to UCL repair published in the English language from January 1, 2010 through December 31, 2019 were eligible for inclusion. To best gauge overall academic interest, all paper qualities and levels of clinical evidence were included regardless of data contribution. Those publications relating to the ulnar collateral ligament of the thumb were excluded. Other exclusion criteria included UCL repair in the context of trauma, fracture, fracture-dislocations, or concomitant lateral ulnar collateral ligament surgery likely indicating a high-energy traumatic context such as a motor vehicle collision. All included records were then identified as reviews, basic science or techniques, clinical studies, and editorials. These papers were categorized by publication year and charted in a histogram format using Microsoft Excel (Excel Version 16.52; Microsoft, Redmond, WA, USA) to allow for subjective visual analysis.

      Statistical Analyses

      All statistical analyses were performed using SPSS version 26 (IBM Corp., Armonk, NY, USA). Comparison of frequencies between dichotomous variables were performed using Fisher Exact tests. Year-over-year operative frequencies were compared using one-way ANOVA with post-hoc Tukey tests. Non-parametric analyses were substituted when data were not normally distributed. Weighted linear regressions were performed to compare the annual rate of change in the frequency of UCL reconstruction and repair procedures from 2010-2019. Statistical significance level alpha was set a priori at 0.05.

      Results

      Procedural Volume

      A total of 1,769 patients met inclusion criteria consisting of 1,255 records for UCL reconstruction and 514 for UCL repair. A total of 105 records were identified as post-traumatic and subsequently removed from the data sample (fracture [CPT 24685, N=18], LCL injury [CPT 24343, N=70; CPT 24344, N=24]). The remaining 1,664 records consisted of 1,180 unique UCL reconstruction procedures and 484 UCL repairs.
      Total UCL surgical volume of both types increased significantly from 2010 to 2019 (N=25 and N=315, respectively). The overall annual incidence of UCL surgery in 2010 was 0.08 persons per 100,000 people in the State of Texas. This grew to 1.02 persons per 100,000 in 2019, an eleven-fold increase. In 2010, UCL repair constituted 23% of all UCL surgeries and steadily increased to 40% of the 315 interventions by the end of 2019 (Figure 1). Weighted linear regression indicated that the frequency of UCL repair increased at a 5.4% faster annual rate than UCL reconstruction from 2010-2019 ​​(B=0.054 [95% CI, 0.028-0.080], R2=0.70, P<0.001).
      Figure thumbnail gr1
      Figure 1Comparison of procedural volumes of UCL repair and reconstruction from 2010-2019 with an overlay of the number of repairs per reconstruction indicating an increasing proportion of UCL repair.

      Demographics, Charges, and Associated Procedures

      Of all the demographic categories analyzed in this study, the most highly represented demographics were white-identifying males aged 18-44 years who underwent surgery in a metropolitan ambulatory surgical center. Most commonly, procedures were covered by private insurance. There were no significant differences between any demographic data, including patient gender, age, ethnicity, or insurance coverage for UCL repair versus reconstruction. The only notable exception existed for patients in rural surgical settings, who had 1.8 times greater odds of undergoing reconstruction (P=0.05 [95% CI, 1.0-3.3]).
      A key benefit of the THCIC database is the inclusion of all payors, thus allowing a comprehensive comparison of charges for any patient who received UCL surgery. As seen in Table 1, there were no differences in patient-level charges between patients receiving repair or reconstruction from 2010 through 2019 (P=0.47), as well as any individual year within this time range.
      Table 1Patient charge data comparisons for all repair and reconstruction for each year from 2010 through 2019, in addition to all years combined. There were no significant differences between the two groups for any time point.
      YearRepair NRecon NRepair ChargesReconstruction ChargesP value
      2010520$14,472.86$12,822.860.57
      201122112$14,673.78$17,130.040.43
      20123894$17,242.11$17,705.390.55
      201343132$23,034.10$20,828.880.40
      201444144$24,359.67$23,542.490.88
      201557127$26,369.68$23,584.910.09
      201660144$26,755.47$29,040.980.40
      201749122$23,558.80$28,144.000.06
      201874165$23,558.80$28,144.000.82
      2019124191$26,901.33$28,706.840.37
      All Years5161251$25,103.23$24,433.910.47
      Between UCL repair and reconstruction, there were no significant differences among commonly associated procedures, namely ulnar nerve surgery (N=114 and N=429, respectively; P=0.217), elbow arthroscopy (N=22 and N=102, respectively; P=0.092), and PRP injection (N=9 and N=29, respectively; P=0.837). Complete demographic data and associated procedure comparisons can be seen in Table 2.
      Table 2Demographic data for all UCL reconstruction and repair from 2010-2019 showing likelihoods of receiving reconstruction over repair. There were no significant differences in any category except for rural surgical settings in which patients were significantly more likely to undergo reconstruction.
      ProcedureTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       Scope10222800.0921.5210.937-2.468
       PRP299200.8370.9060.410-2.004
       Ulnar Nerve4291143150.2171.1760.010-1.504
      GenderTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       Male144541710280.7461.0660.778-1.460
       Female21264148---
      RaceTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       Hispanic210591510.8081.0450.757-1.441
       White11693378320.8131.0320.818-1.300
       Black4813350.8721.1040.579-2.105
       Asian13670.2180.4740.158-1.417
       Native American2111.0000.4080.025-6.541
       Other4291253040.9510.9920.779-1.264
      Age (Years)TotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       <185631504130.1381.1920.950-1.495
       18-449953006950.2250.8690.774-1.058
       45-648728590.5540.8530.538-1.356
       65+174130.7911.3310.432-4.103
      CityTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       Metro12533668870.3030.8080.551-1.184
       Micro8025550.6120.8810.541-1.434
       Rural7614620.05*1.838*1.017-3.322*
      Payor StatusTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       Private146342510380.9340.980.707-1.360
       Medicare196131.0000.8840.334-2.339
       Medicaid4610360.3241.4850.731-3.017
       Worker's Comp9028620.7200.8990.568-1.424
       Self-Pay3711261.0000.9650.473-1.968
       Other7251.0001.0210.197-5.282
      SettingTotalRepairReconstructionChi Square P-valueOdds RatioOR 95% CI
       ASC11003117890.3611.110.888-1.386
       Academic206631430.6230.9170.668-1.260

      Literature Query

      The initial query returned a total of 336 results, of which 60 met inclusion criteria. After duplicate studies were removed, 47 unique publications remained that either directly studied or discussed UCL repair of the elbow from 2010 through 2019. The yearly publications ranged from zero between the years 2011 through 2014 to a maximum of 19 papers published in 2018. The overall frequency by year appears consistent with the general trend of repair procedural volume during this same period, as illustrated by overlaying repair procedural volume on the number of yearly relevant publications (Figure 2). This trend indicates a recent increase in the academic interest in UCL repair that parallels the measured clinical pattern changes. A breakdown of publication types showed 42% of papers were basic science or technique papers, 29% were literature reviews, 26% were clinical studies, and 2% were editorials.
      Figure thumbnail gr2
      Figure 2Histogram showing publications either directly studying or discussing UCL repair with overlay of repair procedural volume from 2010 through 2019.

      Discussion

      Procedural Volume and Academic Interest

      The total interventional volume for elective UCL surgery increased significantly from 2010 through 2019, consistent with the descriptions of prior studies.
      • Erickson B.J.
      • Nwachukwu B.U.
      • Rosas S.
      • Schairer W.W.
      • McCormick F.M.
      • Bach Jr., B.R.
      • et al.
      Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011.
      ,
      • Hodgins J.L.
      • Vitale M.
      • Arons R.R.
      • Ahmad C.S.
      Epidemiology of Medial Ulnar Collateral Ligament Reconstruction: A 10-Year Study in New York State.
      Although both UCL repair and reconstruction increased steadily during this time, surgical repair exhibited a greater overall increase. At the beginning of the data period, repair constituted 24% of all interventions but had increased to 40% by 2019. While we cannot conclude a causal relationship to this trend, it may reflect physicians’ recognition of the improving outcomes of surgical repair over reconstruction, as noted in recent years.
      • Dugas J.R.
      • Looze C.A.
      • Capogna B.
      • Walters B.L.
      • Jones C.M.
      • Rothermich M.A.
      • et al.
      Ulnar Collateral Ligament Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes.
      ,
      • Savoie F.H.
      • Trenhaile S.W.
      • Roberts J.
      • Field L.D.
      • Ramsey J.R.
      Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament.
      Patients who previously would have received UCL reconstruction may instead be undergoing ligament repair due to improved outcomes or perceived expanding indications.
      An alternative explanation for the shift in clinical practice toward UCL repair could be recency bias in the context of a higher volume of publications discussing UCL repair in recent years. To evaluate the premise of this notion, we performed a query the two largest databases, PubMed and Embase, to quantify the academic interest in the topic. As can be seen in Figure 2, there remained a relative dearth of literature until 2015, after which the majority of studies from the last decade were published. This recent eruption of literature shortly precedes a distinct rise in clinical frequency of UCL repair, representing the expected correlative relationship between published literature and clinical practice. Of the 47 publications, the largest category were basic science or technique papers which is consistent with increasing industry interest in the procedure. This of course would not explain the volume of repair which existed prior to the 2015 increase in literature production. These cases may represent the baseline interest of surgeons based on the preexisting studies.
      Another consideration in driving factors behind the changing repair rates is the weighting-effect of a single busy surgical center. When analyzing a relatively uncommon procedure such as isolated UCL repair, a very busy practice could skew the generalizability to the surgeon population as a whole. In order to address this, a post-hoc analysis was performed of the ten most productive UCL repair institutions. The busiest institution constituted 23% of all UCL repair during the study period with the second-busiest contributing 10%. When the top institution was removed from the dataset, the repair growth curve maintained the same inflections as before, reducing concern for single-group confounding.

      Demographics

      Despite the increasing frequency of UCL repair and its reported outcomes, it remains unclear where it is possible to systematically direct patients toward reconstruction versus repair. Considerations for successful UCL repair are reported to include factors such as chronicity and location of the injury, quality of ligament tissue, and patient age.
      • Torres S.J.
      • Limpisvasti O.
      Ulnar Collateral Ligament Repair of the Elbow—Biomechanics, Indications, and Outcomes.
      As a result, one may infer that UCL repair would be more prevalent in a younger cohort, who may have sustained less repetitive soft tissue trauma. However, the demographic analysis performed in this study indicated that there were no differences in patient gender, age, ethnicity, payor coverage, or total charges. It is important to note that the ages within this demographic database are grouped into categories to protect patient confidentiality. As a result, differences in mean age between the two cohorts may exist but cannot be identified precisely. However, even within the pediatric cohort (<18), which would include only patients who are not yet at a collegiate or professional level, there was no difference in surgical procedure. Surgical setting was the only relevant predictor for which procedure was performed, with rural centers 1.8 times more likely to offer UCL reconstruction. We hypothesize that these centers may be less quick to adopt newer techniques such as UCL repair.
      Of the 1,769 records assessed in this study, privately insured, white males aged 18 to 44 were most likely to undergo surgical treatment for UCL injury. In comparison, the 2015 study by Erickson et al, which performed a similar database study concerning exclusively UCL reconstruction from 2007 to 2011, reported that patients aged 15 to 19 were more likely to undergo UCL reconstruction than any other age group. This difference between our current study and the Erickson study may be attributed to the different populations assessed. Specifically, the Erickson study was based on a private-insurance database, in contrast with the current study, which included all payor statuses. The introduction of worker’s compensation, which represents most professional baseball players, may explain the older average age of patients undergoing UCL surgery. Thus, while the database is geographically limited, it provides the most holistic view to date of the relevant patient population.

      Associated Procedures

      This study analyzed three procedures commonly performed alongside UCL surgery (ulnar nerve surgery, elbow arthroscopy, and PRP injection). Due to the nature of a retrospective billing database study, it was not possible to directly identify specific pathology (e.g., specific tear location or severity). We utilized these associated procedures as surrogates to provide a relative comparison of the nature of UCL injury between patients undergoing repair versus reconstruction. There were no significant differences between the two cohorts for any of the three most performed associated procedures. This suggests that concomitant injuries did not play a significant role in determining which intervention was performed.

      Conclusion

      Surgical reconstruction and repair for UCL injuries are increasingly common. From 2010 through 2019, both methods of surgical treatment increased significantly, with reconstruction remaining the most common technique comprising 60% of all surgical interventions in 2019. However, the incidence of UCL repair increased at a higher rate than that of reconstruction, reflecting its growing popularity. This growth of UCL repair over reconstruction correlates with increasing academic interest in UCL repair over recent years, during which several publications have reported more favorable outcomes than earlier studies. When comparing the patient populations undergoing both treatments, there were no significant differences regarding patient gender, age, ethnicity, or insurance coverage. Additionally, there was no difference in concomitant procedures or total charges between the two cohorts. With minimal demographic differences between the two interventions, it can be inferred that patients who previously would have undergone UCL reconstruction are now receiving repair. Future studies should seek to further clarify surgical indications for each respective intervention.

      Limitations

      This study is not without limitations. The strength of this study is limited by its retrospective nature with a primary purpose of pattern identification. Other states or regions may exhibit differing practice patterns because of cultural or economic differences than those exhibited in the State of Texas. Outcome data is not available. While the use of a billing database allows for analysis of large populations, they are necessarily limited in their detail regarding individual patient characteristics or the extent or specific location of ligament tears. Some categorizations are broadly defined. They are also subject to confounding from billing inaccuracies; however, these errors would likely have remained constant throughout the data collection period.
      Trends in UCL Surgery

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