Interobserver and Intraobserver Reliability of an MRI-Based Classification System for Injuries to the Ulnar Collateral Ligament

Ramkumar, Prem N.; Frangiamore, Salvatore J.; Navarro, Sergio M.; Lynch, T. Sean; Forney, Michael C.; Kaar, Scott G.; Akhavan, Sam; Moutzouros, Vasilios; Westermann, Robert W.; Farrow, Lutul D.; Schickendantz, Mark S.

doi:10.1177/0363546518786970

Cited by 23 publications

(28 citation statements)

References 23 publications

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“…Higher grade UCL tearing often results in valgus instability of the elbow, a career-threatening injury to throwing athletes that often requires surgery, especially in distal and complete tears (►Table 1). 31 Handball field players are at risk for this injury complex but to a lesser degree than baseball pitchers. Reasons may include differences in biomechanics and lower degrees of elbow flexion during throwing.…”

Section: Elbowmentioning

confidence: 99%

Sports Imaging of Team Handball Injuries

Parkar

Cerezal

Storgaard³

et al. 2020

Semin Musculoskelet Radiol

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Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

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Section: Elbowmentioning

confidence: 99%

Sports Imaging of Team Handball Injuries

Parkar

Cerezal

Storgaard³

et al. 2020

Semin Musculoskelet Radiol

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“…In this study, a previously proposed 6-stage MRI-based classification system with high intraobserver and interobserver reliability, accounting for location and severity of UCL tears, was found to carry clinical decision-making value for both the general population and baseball players alike. 6,23 UCL tears in both general athletes and baseball players, regardless of position, were found to more frequently fail nonoperative management, despite a specialized rest and rehabilitation program if the tear was distal (stage 3) and complete (substage B). For baseball players specifically, distal tears were 36 times more likely and complete tears 7 times more likely to fail nonoperative management and require surgery.…”

Section: Discussionmentioning

confidence: 97%

“…These authors found that 9 of 11 patients who failed nonoperative management had distal tears, and 17 of 21 who did not fail had proximal tears, suggesting that location may play a role in treatment decision making. Ramkumar et al 23 introduced an MRI-based classification system that accounted for both tear location and severity (Table 1), which demonstrated high intraobserver and interobserver reliability among 9 readers across multiple institutions.…”

mentioning

confidence: 99%

Clinical Utility of an MRI-Based Classification System for Operative Versus Nonoperative Management of Ulnar Collateral Ligament Tears: A 2-Year Follow-up Study

Ramkumar

Haeberle

Navarro

et al. 2019

Orthopaedic Journal of Sports Medicine

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Background: A recently introduced classification system of medial ulnar collateral ligament (UCL) tears accounting for location and severity has demonstrated high interobserver and intraobserver reliability, but little is known about its clinical utility. Purpose: The primary purpose of this study was to assess the relationship of the magnetic resonance imaging (MRI)–based classification system in predicting which athletes had success with nonoperative versus operative treatment after completing a standardized rehabilitation program. A secondary objective included return to play (RTP) and return to prior performance (RPP) analyses of baseball players. Study Design: Cohort study; Level of evidence, 3. Methods: After an a priori power analysis, 58 consecutive patients with UCL tears and a minimum of 2-year follow-up were retrospectively divided into 2 groups: those who successfully completed operative treatment and those who completed nonoperative treatment. The MRI-based classification stages accounting for UCL tear location and severity were compared between the nonoperative and operative groups. A subanalysis for baseball players, including RTP and RPP, was performed. Results: A total of 58 patients (40 baseball players [34 pitchers]) met inclusion criteria. Of these patients 35 (32 baseball players [27 pitchers]) underwent surgery, and 23 (8 baseball players [7 pitchers]) underwent nonoperative management. No patients in the nonoperative arm crossed over to surgery after completing the rehabilitation program. Patients with distal tears (odds ratio, 48.0; P = .0004) and complete tears (odds ratio, 5.4; P = .004) were more likely to undergo surgery. Baseball players, regardless of position, were confounding determinants of operative management, although there was no difference in RTP and RPP between treatment arms. Conclusion: A 6-stage MRI-based classification system addressing UCL tear location and severity may help early decision making, as patients likely to fail nonoperative treatment have complete, distal tears, whereas those with proximal, partial tears may be more amenable to nonoperative management.

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“…Greater attention is being paid to the grade, anatomic location, and completeness of UCL injury, as demonstrated by 3 recently proposed MR-based classification schemes (Table 2). 25,29,30…”

Section: Discussionmentioning

confidence: 99%

“…Recent studies have suggested that partial injuries occurring in different anatomic locations may behave differently and that some may be amenable to nonoperative management. 15,16,19,21,[29][30][31][32] Unfortunately, uniform consensus has not yet been achieved regarding what tear locations result in the greatest instability or poorest outcomes with nonsurgical treatment. The purpose of this study was to determine the amount of ulnohumeral joint space gapping measured using stress ultrasound with applied valgus stress that occurs with clinically relevant partial tears of the UCL in a cadaveric model as compared with that of the intact and completely torn states.…”

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confidence: 99%

Medial Elbow Instability Resulting From Partial Tears of the Ulnar Collateral Ligament: Stress Ultrasound in a Cadaveric Model

et al. 2020

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Background: There is consensus that most complete ulnar collateral ligament (UCL) injuries in throwers would benefit from surgical intervention. Optimal treatment for partial UCL tears remains controversial. Stress ultrasonography has become a well-accepted diagnostic modality for assessing UCL injury. Hypothesis: Partial UCL tears will result in an intermediate increase in ulnohumeral joint space gapping as compared with that of an intact UCL and a complete UCL tear, but the degree of joint space gapping will vary by anatomic location of the partial tear. Study Design: Controlled laboratory study. Methods: Twenty-one cadaveric elbows were divided into 7 groups representing different anatomic locations of UCL partial tears. Partial tears were simulated by cutting 50% of the measured width of the UCL at 6 locations: distal anterior/posterior, midsubstance anterior/posterior, and proximal anterior/posterior. A seventh partial tear was created by partially elevating the undersurface of the distal UCL to simulate the radiographic “T-sign.” Valgus stress (15 daN) was applied to each cadaveric elbow at 30° of flexion using a standardized device. Each specimen was tested intact, partially torn, and completely torn. At each state, joint space was measured using stress ultrasonography, and the difference in joint space from unstressed to stressed (delta) was recorded. Results: There were 10 right and 11 left upper extremity specimens. The mean delta was 0.58 mm for the intact state and <0.75 mm in all groups. Both distal partial tear groups had mean deltas <0.75 mm, similar to intact elbows. Proximal tears and the T-sign demonstrated intermediate deltas (0.99-1.23 mm). Midsubstance partial tears demonstrated the largest deltas (1.57-2.03 mm), similar to those of the complete tears. All complete tear groups had a mean delta >1.5 mm (1.54-3.03 mm). Conclusion: These findings suggest that partial tears introduce a spectrum of instability from functionally intact to completely torn. As a result, some may be biomechanically amenable to nonoperative treatment, while others would be indicated for early reconstruction. Further research into the biological and biomechanical determinants of nonoperative treatment failure will assist with more precise treatment recommendations. Clinical Relevance: Describing the biomechanical consequences of different, clinically significant partial UCL tears potentially allows more precise recommendations for operative and nonoperative treatment.

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Interobserver and Intraobserver Reliability of an MRI-Based Classification System for Injuries to the Ulnar Collateral Ligament

Abstract: The newly proposed 6-stage MRI-based classification utilizing grade and location of the injury had substantial to near perfect agreement among and within fellowship-trained observers.

Cited by 23 publications

References 23 publications

Sports Imaging of Team Handball Injuries

Sports Imaging of Team Handball Injuries

Clinical Utility of an MRI-Based Classification System for Operative Versus Nonoperative Management of Ulnar Collateral Ligament Tears: A 2-Year Follow-up Study

Medial Elbow Instability Resulting From Partial Tears of the Ulnar Collateral Ligament: Stress Ultrasound in a Cadaveric Model

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