M.J. Richard and D.S. Ruch reply:
While all of the eleven patients included in our study were athletes, only three were overhead athletes. However, all patients were evaluated for concomitant injuries and pathological conditions of the elbow, as reported in our study. None of the overhead athletes reported a history of pain through the deceleration phase of throwing prior to the injury, and none of the imaging studies revealed evidence of posteromedial impingement of the olecranon.
Vitale and Ahmad documented that newer muscle-splitting and docking techniques of ulnar collateral ligament reconstruction without obligatory transposition of the ulnar nerve led to improved outcomes and lower rates of ulnar neuropathy1. Closer examination of this review article shows that other authors have found the rates of ulnar neuropathy associated with subcutaneous or subfascial transpositions to be much lower than the rates associated with submuscular transposition, as was routinely performed with earlier techniques2,3. We performed subfascial ulnar nerve transposition in all of our patients. Preoperative ulnar neuropathy was the reason for the transposition in three of these patients. Seven patients had extensive mobilization of the ulnar nerve to facilitate ligament repair and underwent transposition because of subluxation of the nerve. In the final patient, the ulnar nerve was transposed because of concern that it would be irritated by the suture material utilized for the ligament repair.
Finally, in an in vitro study, Pichora et al. demonstrated favorable results with a broad range of acceptable tensions for the ulnar collateral ligament of the elbow4. We did not measure the tension of the ligament repair. Because our patients had ligament repairs and not reconstructions, the native anatomy was easily recreated. We placed the elbow in midflexion and slight varus at the time of the repair to allow appropriate matching of the ligament origin to the footprint on the medial epicondyle.
These letters originally appeared, in slightly different form, on . They are still available on the web site in conjunction with the article to which they refer.