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Abstract

Background:

The incidence of medial ulnar collateral ligament (MUCL) reconstruction has increased significantly over the past 2 decades, especially in professional baseball. While new literature has demonstrated that MUCL repair is a viable alternative in the correct patient population with the potential for faster return to play, there have been no recent population-based studies comparing the incidence of the 2 procedures to determine how widespread the adoption of MUCL repair has become.

Purpose/Hypothesis:

The purpose of this study is to examine the epidemiological trends of MUCL repair compared with reconstruction on a statewide level over a 5-year period. The primary outcomes were the annual rates of MUCL repair and reconstruction. Secondary outcomes included patient demographics, institutional and surgeon volumes, and concomitant ulnar nerve transposition.

Study Design:

Descriptive epidemiological study.

Methods:

The New York Statewide Planning and Research Cooperative System database was queried for all MUCL repairs and reconstructions in New York State from 2017 to 2021 utilizing outpatient Current Procedural Terminology, 4th Revision codes. Data obtained included concomitant ulnar nerve surgery, patient age, sex, ethnicity, insurance, and laterality, as well as institutional and surgeon volume.

Results:

From 2017 to 2021, there were 745 MUCL surgeries performed in New York State: 242 repairs and 503 reconstructions. The incidence of MUCL repairs increased by 133% while reconstructions increased by 48% during this time period. Patients ≤16 years of age underwent MUCL repair at a significantly higher rate than college-aged patients between 19 and 22 years of age (40.9% vs 21.9%; P < .001). Female patients underwent repair at a rate 2.88 times higher than male patients. There was no difference in the type of surgery between patients with private or public insurance.

Conclusion:

The overall rate of MUCL surgery has increased significantly over recent years. With advances in surgical technique and technology demonstrating the potential for faster return to play, MUCL repairs have continued to grow in popularity. This trend is most evident among teenage patients.

Keywords

baseball/softball elbow general sports trauma epidemiology medical aspects of sports medial ulnar collateral ligament

Injury to the medial ulnar collateral ligament (MUCL) is common in the overhead throwing athlete. Since Dr. Frank Jobe performed the first reconstruction of the MUCL in 1974, many advances have occurred, allowing for faster and more reliable return to sport.^3,19 MUCL reconstruction has become particularly prevalent in professional baseball with prominent coverage in the media.⁸ Previous data reported a surge in MUCL reconstructions performed in New York State (NYS) from 2002 to 2011.¹⁷ While the popularity of MUCL reconstructions grew in the early 2000s, MUCL repair had been largely abandoned because of poor early results.² However, in 2008, Savoie et al³³ published their positive findings utilizing suture anchors to repair the MUCL. During the latter part of the past decade, Dugas et al^12,14 demonstrated that repair with high-strength suture augmentation enabled patients to return to sport at a high rate after a mean of 6.7 months. These advances have revived an interest in MUCL repair. To date, there have been no population-based studies comparing the incidence of MUCL reconstructions compared with repairs since the repair technique with high-strength suture augmentation was published as a viable surgical option.

The primary aim of this study is to examine the epidemiological trends of MUCL repair compared with reconstruction on a statewide level from 2017 to 2021. The subsequent goal was to identify a possible paradigm shift in the management of operative MUCL injuries. The primary outcomes were the annual rates of MUCL repair and reconstruction. Secondary outcomes included patient demographics, institutional and surgeon volumes, and concomitant ulnar nerve transposition. We hypothesized that the incidence of MUCL repair in NYS had risen significantly more than reconstruction over the 5-year period.

Methods

The New York Statewide Planning and Research Cooperative System (SPARCS) database contains information for every NYS ambulatory discharge. The database was queried for patients between the ages of 13 and 36 years old using outpatient Current Procedural Terminology, 4th Revision, codes 24345 and 24346 to obtain all MUCL repairs and reconstructions, respectively, in NYS from 2017 to 2021. After identification of all MUCL operations, no cases were excluded. Data obtained included concomitant ulnar nerve surgery (yes/no), patient age, sex (male vs female), race/ethnicity (White, Hispanic, Black, Asian), insurance (private vs Medicaid), laterality (right vs left). The operating surgeon and institution were also collected. Within a case, any missing metric was considered unknown. Annual NYS population estimates were obtained from the US Census Bureau to determine rates of MUCL operations calculated per 100,000 people.

Statistical Analysis

Statistical analysis was performed with SPSS Version 28 (IBM Corp). The data were checked to assure that assumptions for parametric tests were met. Descriptive statistics for continuous variables are presented as the mean and standard deviation, and categorical variables are presented as percentages. Frequency distributions were evaluated through chi-square tests. In multiple regressions, continuous variables were not modified while categorical variables were converted to indicator values. Multiple binary logistic regression models (0, 1) were used to determine which variables were associated with the surgical technique performed (MUCL reconstruction vs MUCL repair). The following independent variables were included in the model: surgery year (continuous), age (continuous), sex (male vs female), and insurance (private vs Medicaid). Race/ethnicity was omitted from multivariate analysis because a high proportion of cases were missing data. For all types of analysis, a P value ≤.05 was considered statistically significant. Patients were additionally subdivided into the following age cohorts for separate analysis: 13-16, 17-18, 19-20, 21-22, and 23-25, as well as ≥26.

Results

From 2017 to 2021, there were 745 MUCL surgeries performed in NYS: 242 repairs and 503 reconstructions (Table 1).

Table 1

Patient Demographics ^a

	Reconstruction	Repair	Total
Surgeries	503 (67.5)	242 (32.5)	745
Ulnar nerve transposition	167 (33.2)	76 (31.4)	243 (32.6)
Age, y	19.7 ± 3.9	20.1 ± 5.6	20 ± 4.5
Sex
Male	466 (92.6)	198 (81.8)	664 (89.1)
Female	37 (7.4)	44 (18.2)	81 (10.9)
Insurance
Private	429 (85.3)	203 (83.9)	632 (84.8)
Medicaid	45 (8.9)	27 (11.2)	72 (9.7)
Unknown	29 (5.8)	12 (5.0)	41 (5.5)
Race
White	237 (47.1)	134 (55.4)	371 (49.8)
Hispanic	30 (6.0)	5 (2.1)	35 (4.7)
Black	9 (1.8)	6 (2.5)	15 (2.0)
Asian	6 (1.2)	4 (1.7)	10 (1.3)
Unknown	221 (43.9)	93 (38.4)	314 (42.1)

Data are presented as n (%) or mean ± SD.

Between 2017 and 2021, there was a 72% increase in MUCL surgeries (Figure 1A). The overall rate of MUCL operations increased from 0.597 to 1.01 per 100,000 people (P < .001). Within the umbrella of MUCL operations, the yearly incidence of MUCL repairs increased by 133% while MUCL reconstructions increased by 48% (Figure 1A). Patients who had MUCL surgery were more likely to undergo repair than in previous years; in this timeline, the proportion of MUCL repair operations performed increased significantly from 28% to 38% (P = .03) (Figure 1B). Conversely, the relative proportion of UCL reconstruction decreased from 72% to 62%.

Figure 1.

Incidence of medial ulnar collateral ligament (UCL) surgery in New York State.

The observed increase in incidence of MUCL operations was seen across nearly all age groups (Figure 2A). This was observed for both MUCL reconstruction (Figure 2B) and MUCL repair (Figure 2C). The most dramatic increase in incidence was seen in patients ≤20 years of age, which approximately doubled from 2017 to 2021.

Figure 2.

Incidence of medial ulnar collateral ligament operations by age groups in New York State from 2017 to 2021.

The relative contributions of MUCL reconstruction and MUCL repair to the surgical management of MUCL injuries varied across age groups (Figure 3). Higher frequencies of MUCL repair were seen in the youngest and oldest patient populations. Patients ≤16 years of age underwent MUCL repair at a significantly higher rate than college-aged patients between 19 and 22 years old (40.9% vs 21.9%; P < .001), and post college patients aged 21-25 (40.9% vs 23.3%; P < .001). Furthermore, patients ≤16 years of age were >2 times as likely to undergo MUCL repair than patients 21 to 22 years old. Patients ≥26 years of age had the highest proportion of operations done through repair and were equally as likely to undergo repair versus reconstruction.

Figure 3.

Relative incidence of ulnar collateral ligament (UCL) reconstruction and UCL repair by age groups in New York State from 2017 to 2021.

In multivariate analysis of patient-centered demographics and surgical management with MUCL repair, female sex was found to be the greatest predictor of management with MUCL repair (Table 2). Specifically, female patients were 2.88 times more likely to undergo MUCL repair than their male counterparts. The second greatest predictor of intervention by MUCL repair was the year the procedure took place; for each passing year, the odds of undergoing MUCL repair increased 19.3%. The patient's insurance had no significant effect on the type of surgery performed (P = .62). Given the U-shaped distribution of operation-specific proportions across age groups, when treated as a continuous variable, age did not affect the procedure performed.

Table 2

Multivariate Analysis of Associations Between Patient Characteristics and Surgical Management With MUCL Repair ^a

	SE	Wald	df	P	OR	95% CI
Age	0.18	2.275	1	.13	1.028	0.992-1.065
Insurance	0.266	0.247	1	.62	0.876	0.520-1.476
Sex	0.249	17.999	1	<.001	2.878	1.766-4.691
Surgery year	0.059	8.927	1	.003	1.193	1.062-1.339
Constant	0.495	11.519	1	<.001	0.186

MUCL, ulnar collateral ligament; OR, odds ratio.

Race, in certain comparisons, also influenced the type of operation performed; Caucasian patients were more likely to undergo a repair than Hispanic patients (36.1% vs 14.3%, respectively, P = .009). No significant differences existed between other races such as Black or Asian patients who represented a smaller proportion of the overall patient population. Using New York State Census data for the years studied it was determined that White patients were 7.2 times more likely than Black patients, and 3.78 times more likely than Hispanic patients, to undergo MUCL surgery.

There was no significant increase in the percentage of MUCL surgeries with concurrent ulnar nerve transposition between 2017 and 2021 (31.6% vs 33.5%); P = .83). In multivariate logistic analysis, the type of surgery (repair versus reconstruction), patient's age, patient's sex, the year of surgery, and insurance did not affect the likelihood that the patient would undergo ulnar nerve transposition.

Corresponding with the increased number of cases, there was a 158% increase in the number of surgeons performing reconstructions and a 210% increase in the number performing repairs (Figure 4A). The number of ambulatory surgery centers and hospitals performing reconstructions experienced a 16% decrease while the number performing repairs experienced a significant 66% increase (Figure 4B). Over the time period studied, 61 unique ambulatory surgery centers or hospitals performed a MUCL procedure.

Figure 4.

Incidence of New York surgeons and hospitals performing medial ulnar collateral ligament (MUCL) surgery.

There were 2 high-volume surgeons in NYS who performed a large percentage of all MUCL surgeries. They had a 543% increase in the total number of cases performed between 2017 and 2021. Their practices largely favored reconstruction, but their rate of MUCL repair also increased. These surgeons performed a MUCL transposition in 37.4% of their cases, in line with the overall rate of all surgeons in the state.

Discussion

Since its development, MUCL reconstruction has demonstrated consistently promising results while the outcomes of early attempts at MUCL repair were poor.⁹ Consequently, repair was largely abandoned for many years. However, with the introduction of new techniques and suture material, MUCL repair has experienced a resurgence in popularity. This renaissance has coincided with a continued increase in the operative management of MUCL injuries.

An earlier study by Hodgins et al¹⁷ looked at the number of MUCL reconstructions in NYS between the years of 2002 and 2011 and found that the rate of MUCL reconstructions tripled during the period studied. A recent survey study of the American Board of Orthopaedic Surgery Part II case lists found that between 2010 and 2020, the rate of MUCL repair increased but MUCL reconstruction remained significantly more common.³⁵ However, these time periods encompassed the development and proliferation of new MUCL repair techniques.^3,33 Notably, Dugas et al¹³ demonstrated that the use of high-strength suture augmentation in MUCL repair may lead to quicker return to sport. In their 2018 study, patients were able to return to sport at 6.7 months—a significant improvement over traditional reconstruction. The effect of these new techniques and their increased adaptation is reflected in the results of the present investigation. As seen in previous studies, the number of overall MUCL procedures increased, with reconstruction still being more popular but repair demonstrating faster growth.

This expansion has been reflected in professional, collegiate, and youth athletes. A recent study showed that 26% of Major League Baseball (MLB) pitchers and 19% of minor league pitchers had undergone MUCL reconstruction, a significant increase from a previous study in 2012.²³ These are devastating injuries for professional athletes with a mean return to the same level of competition of between 16.6 and 17.8 months.^4,7 There are fewer data available on the rate of return to MLB after MUCL repair, but a small case series by Malige and Uquillas²⁶ reported that 4 out of 5 MLB players that underwent MUCL repair between 2016 and 2021 returned to pitching at a mean time of 9.55 months.

The mean age of patients undergoing surgery for MUCL injury has also decreased over time.^5,18 Previous studies by Petty et al²⁰ and Jones et al³⁰ demonstrated a greater number of adolescent and teenage athletes undergoing MUCL reconstruction over time. Those findings are further supported by the outcomes of the present study. Several reasons for this trend have been proposed. Despite well-established guidelines on how to best minimize the risk of injury,^15,27 the rise of year-round travel baseball and private pitching coaches has led players to throwing with higher volume and velocity. This greater biomechanical demand heightens the risk of MUCL injury.^22,28 Additionally, the successful return of MLB pitchers after MUCL surgery has galvanized misconceptions regarding the severity and nature of the injury among youth players, parents, and coaches. Many young athletes have expressed interest in undergoing the procedure without injury to improve performance and are unfamiliar with the risk factors that increase their chance of injury.¹ The further increase in youth MUCL injuries demonstrates the need for continued study on the best practices of injury prevention, programs to effectively educate players, coaches, and parents, and a renewed effort by physicians in shaping how the media portrays these injuries.⁸

Interestingly the youngest cohort was more likely to undergo MUCL repair compared with older cohorts. Among patients 13 to 16 years old, repairs accounted for 41% of MUCL surgeries, compared with just 23.3% in those 21 to 25 years old. Reasons for this are likely multifactorial. Older patients have thrown more pitches, placing more chronic wear on their MUCL, which may translate to poorer tissue quality and preclude them from successful repair. Additionally, the cohort of patients aged 21 to 25 has largely finished college and may contain minor league and MLB players. As previously discussed, there are a wealth of data on the return-to-play outcomes of professional players undergoing MUCL reconstruction with comparatively few data for repairs. Therefore, in these patients for whom a return to play is essential to their livelihood, surgeons may be more likely to opt for the more well-established procedure (ie, reconstruction).

Addressing the ulnar nerve during a MUCL procedure remains an evolving topic. A systematic review by Vitale and Ahmad³⁶ demonstrated that the surgical technique employed had a significant effect on the rate of postoperative ulnar neuropathy. They reported that transposition only in the setting of preoperative symptoms led to an additional decrease in postoperative symptoms. A more recent review by Clain et al⁶ found a 16.1% rate of postoperative ulnar neuropathy in those who underwent transposition compared with only 3.9% in those without nerve manipulation, suggesting that surgeons should carefully indicate which patients may benefit from transposition. In our population, the rate of ulnar nerve transposition remained consistent with 31.6% of procedures in 2017 involving a transposition compared with 33.5% in 2021. Patient age, sex, and type of surgery (repair vs reconstruction) did not affect whether a transposition was performed. A study by De Giacomo et al¹⁰ found that 19.7% of their 578 patients undergoing MUCL reconstruction were preoperatively diagnosed with ulnar neuritis. This may suggest that ulnar nerve transposition continues to be performed at a higher-than-optimal rate. This may be reflective of surgeons’ unfamiliarity with the most recent literature or the comfortability of performing their more practiced technique.

Male patients comprised 89.1% of the patient population in the present study. While MUCL injuries are seen in other types of throwing athletes, gymnasts, tennis players, and wrestlers, it most frequently occurs in baseball players secondary to the repetitive valgus stress placed on the medial elbow.²⁴ Among female athletes who underwent MUCL surgery, they were significantly more likely to undergo repair than their male counterparts. White patients were 7.2 times more likely than Black patients, and 3.78 times more likely than Hispanic patients, to undergo MUCL surgery. This discrepancy has narrowed compared with Hodgins et al¹⁷ who reported that non-Hispanic patients were 11.4 times more likely than their Hispanic counterparts to undergo MUCL reconstruction. One potential explanation for the improvement in the disparity could be the passage of the Affordable Care Act and Medicaid expansion since that time. A multitude of reasons may explain this persistent disparity including decreased access to orthopaedic care, lack of access to magnetic resonance imaging, and decreased participation in youth sports, particularly baseball.³¹ This disparity did not hold true for insurance providers, as there was no significant difference in the percentage of patients with public versus private insurance who underwent MUCL repair. Further investigation of the intersection of race and socioeconomic status with the type of MUCL operation utilized is merited and should include larger sample sizes of minority groups to increase statistical power.

Corresponding with the increased number of overall MUCL surgeries, there was a 158.3% increase in the number of surgeons performing MUCL reconstructions and a 210% increase in the number performing MUCL repairs. The number of hospitals and ambulatory surgery centers performing MUCL reconstructions experienced a 16% decrease while the number performing repairs experienced a 66% increase. The larger increase in the number of surgeons performing MUCL repairs and at more locations may reflect a younger generation of surgeons emerging from training comfortable with repair techniques. It may also represent a group of surgeons transitioning some of their practice from MUCL reconstructions to repairs based on the literature. It is important to note that over the 5-year period studied, a total of 61 different locations performed a MUCL repair, but the number of locations performing the surgery never exceeded 25 in any given year. This means many locations were not performing even a single procedure each year. While having an increased number of locations capable of performing MUCL surgery is positive for patient access, centers that are unfamiliar with the complex technical requirements of a particular surgery may experience worse outcomes compared with their high-volume counterparts.^25,34

Limitations

The limitations of this investigation include those inherent to all retrospective and database studies. The SPARCS database is well-maintained and has provided insight into multiple orthopaedic injuries^11,16,17,37; however, coding errors remain possible.³² While an excellent resource for epidemiologic study, the database does not provide granular detail about the individual patient, so the exact timing, mechanism, and location (humeral versus ulnar vs midsubstance) of injury for the patients studied are unknown. Therefore, while it is hypothesized that the rise in MUCL repair was driven by the positive outcomes of repair with high-strength suture augmentation, it is possible that some of the repairs included in this study did not utilize this technique. It is important to consider that while classically MUCL injuries occur in overhead throwing athletes, they also may occur due to traumatic injury or in nonthrowing athletes. In this data set, it is unknown what percentage of cases were indicated for traumatic injury or nonthrowing athletes versus overhead throwing athletes. Traumatic MUCL injuries often take place in a different demographic, and the inability to exclude them may confound the results of this study. Finally, this study is limited to the trends of only 1 state. Youth sports participation rates vary significantly by socioeconomic status, race, and region.^21,29 Therefore, the trends observed in NYS may not accurately represent the entire country. It is also important to note that the time period studied includes the COVID-19 pandemic during which time many elective cases were delayed or canceled. It is possible that the number of MUCL surgeries performed would have been greater if not for the pandemic, particularly in 2020. Despite these limitations, this paper presents an analysis of a large, diverse population that will provide valuable insight to orthopaedic surgeons. It will also serve as an important comparison point for future research into the trends of MUCL surgery.

Conclusion

The overall rate of MUCL surgeries has increased significantly over recent years. With advances in technique and technology demonstrating the potential for faster return to play, MUCL repairs have continued to grow in popularity. This trend is most evident among patients 13 to 16 years old. As more surgeons become comfortable performing MUCL repairs, it is possible that the incidence of repair will approach that of reconstruction.

Footnotes

Final revision submitted April 26, 2025; accepted June 13, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: Access to the New York State SPARCs database was sponsored by the Northwell Health Long Island Jewish Medical Center Department of Orthopedics. This publication was produced from raw data purchased from or provided by the NYSDOH. NYSDOH, its employees, officers, and agents make no representation, warranty, or guarantee as to the accuracy, completeness, currency, or suitability of the information provided here. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval was not sought for the present study.

ORCID iDs

Lt. Matthew A. Zinner

Brian D. Greenstein

Katherine Kachkarov

Eric V. Neufeld

William Degouveia

Steven E. Rokito

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Epidemiology of MUCL Repair and Reconstruction: A 5-Year Study in New York State

Abstract

Background:

Purpose/Hypothesis:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Statistical Analysis

Results

Discussion

Limitations

Conclusion

Footnotes

ORCID iDs

References