Is K Wire Needed To Repair Rupture Of The Ulnar Collateral Ligament

Version ane. F1000Res. 2022; 7: 714.

Therapeutic interventions for acute complete ruptures of the ulnar collateral ligament of the pollex: a systematic review

Marking Mikhail, Formal Analysis, Investigation, Methodology, Writing – Original Typhoon Preparation, Writing – Review & Editing,¹ Justin C. R. Wormald, Conceptualization, Formal Analysis, Methodology, Project Administration, Supervision,^2, ^three Neal Thurley, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing,^four Nicholas Riley, Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing,⁵ and Benjamin J. F. Dean, Conceptualization, Formal Analysis, Investigation, Methodology, Projection Administration, Supervision, Validation, Writing – Original Typhoon Grooming, Writing – Review & Editing ^a, ^2, ^v

Marker Mikhail

^oneDepartment of Plastic, Reconstructive and Paw Surgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK

Justin C. R. Wormald

²Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Center, University of Oxford, Oxford, OX3 7LD, U.k.

ⁱⁱⁱDepartment of Plastic, Reconstructive and Burns Surgery, Stoke Mandeville Hospital, Aylesbury, HP21 8AL, UK

Neal Thurley

⁴Bodleian Health Care Libraries, Cairns Library, John Radcliffe Infirmary, Oxford, OX3 9DU, UK

Nicholas Riley

⁵Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LD, UK

Benjamin J. F. Dean

ⁱⁱNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Academy of Oxford, Oxford, OX3 7LD, United kingdom of great britain and northern ireland

⁵Nuffield Orthopaedic Centre, Oxford Academy Hospitals NHS Foundation Trust, Oxford, OX3 7LD, UK

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Information Availability Argument: All data underlying the results are available as part of the article and no boosted source information are required.

Peer Review Summary

Review date	Reviewer name(s)	Version reviewed	Review condition
2018 Jul 2	Charles Pailthorpe	Version ane	Canonical
2018 Jun 21	Harpal Uppal	Version 1	Approved

Abstruse

Background: The aim of this study was to evaluate the effectiveness of interventions for acute complete rupture of the ulnar collateral ligament (UCL) of the thumb in adults.

Methods: The post-obit databases were searched: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO, from database inception to 31 ^st January 2022. Inclusion criteria were: (i) randomised controlled clinical trials (RCTs) or study of intervention with a comparator; (ii) participants with diagnosis of acute consummate rupture of the UCL of the thumb; (iii) participants anile eighteen years of age or older at enrolment; and (iv) published in a peer-reviewed English-linguistic communication journal.

Results: In total, six studies were identified for inclusion after screening. All studies had a high run a risk of bias. Iii studies were retrospective comparative case series which compared two different surgical techniques (bone anchor versus pull out suture, suture versus pull out suture, suture versus steel wire). Of these studies, three were RCTs, two of which compared different rehabilitation regimes in patients managed surgically (plaster versus early mobilization, new spica versus standard spica). The remaining RCT compared two different rehabilitation regimes in a mixed group of surgically/non-surgically treated patients. The RCT comparing a standard spica with a new spica demonstrated a statistically significant comeback in outcomes with the new spica at all time points (range of motion, Dreiser alphabetize and VAS); this was also the but study to provide sufficient upshot information for further assay.

Conclusion: There is no prospective evidence comparing surgery to non-operative treatment for acute complete ruptures of the ulnar collateral ligament of the thumb. There is weak evidence to suggest that early on mobilisation may be benign post-obit surgical repair. Further inquiry is necessary to better define which patients do good from which specific interventions.

Keywords: ulnar collateral ligament; pollex; rupture; surgery

Introduction

Astute complete ruptures of the ulnar collateral ligament (UCL) of the pollex are mutual injuries, bookkeeping for around fifty in 100,000 presentations to Blow and Emergency departments. There is controversy as how to manage consummate ruptures of the UCL best, although in that location is a degree of consensus regarding the broader treatment algorithm and general understanding that 'truthful' Stener lesions should exist managed operatively ^{i, two}. The rate of the Stener lesion varies widely in the literature, perhaps reflecting the lack of reliability and accurateness of the various methods of diagnosis ^{iii, iv}.

Patients should exist assessed clinically to determine the caste of instability of the metacarpophalangeal joint (MCPJ) in both extension and 30° of flexion to test both proper and accessory collateral ligaments ⁵. In that location is some evidence to suggest that the greater the instability the higher the chances are that a Stener lesion is nowadays ^{vi, 7}. While there is evidence to support both the use of ultrasound and MRI, the latter appears slightly superior in terms of sensitivity and specificity ^{8– 10}. A recent study by Stoop et al. investigated which factors predict the chances of surgery in UCL injuries ¹¹. It was found that not only did patient characteristics influence the chances of surgery, only that the individual surgeon's preference was also predictive.

Our aim was to perform a systematic review of the effectiveness of bachelor interventions for acute complete rupture of the ulnar collateral ligament of the thumb in terms of patient-reported effect measures and to assess the rates of adverse outcomes associated with these interventions.

Methods

The systematic review was adult in accordance with the PRISMA argument ( Supplementary File 1 contains a completed PRISMA checklist), using methodology decribed in the Cochrane Handbook for Systematic Reviews of Interventions. The protocol was adult prospectively and peer reviewed locally before registration on the PROSPERO database ( CRD42018087656).

Data sources and searches

A comprehensive search strategy was created in collaboration with a enquiry librarian (North.T.) and was designed to capture all relevant manufactures pertaining to inventions for acute complete ruptures of the ulnar collateral ligament of the thumb ( Supplementary File two). The total search strategy is detailed on the PROSPERO website. The search strategy was practical to the following bibliographic databases from database inception until 31 ^st January 2022: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO from database inception until 31 ^st Jan 2022.

Inclusion/exclusion criteria

The inclusion and exclusion criteria were defined prospectively during the protocol phase. Any report relating to acute complete ruptures of the ulnar collateral ligament of the thumb MCPJ in adults was included. Studies had to contain an intervention and a comparator (i.due east. both non-randomised controlled trials, and randomised controlled trials, including semi/quasi randomised, cluster randomised trials and comparative instance serial). Any therapeutic intervention or control treatments were included.

Option of studies

Duplicates were removed and relevant studies identified from the search were imported into Covidence for screening. Studies were independently screened by title and abstract by two authors (B.J.F.D. and M.K.). This was followed past a full-text evaluation of the selected studies from the beginning selection step these authors. Disagreement between the two reviewers was solved by consensus involving a 3rd author (J.C.R.Due west.).

Information extraction

2 reviewers (M.M. and B.J.F.D) independently extracted data. Data was extracted using a custom data extraction sail in Covidence. Whatever inconsistencies between the ii reviewers' forms were resolved past consensus discussion. A tertiary review (J.C.R.Westward.) was available for whatsoever disagreement that could not be resolved by this initial discussion.

If data was non bachelor from total-text articles or trial registrations, authors were contacted to provide this data. If authors were not contactable as regards additional information, and so this attribute of the study was excluded from the information synthesis. If contactable authors did non respond to initial requests, they were sent 2 subsequent reminders over a minimum of 6 weeks. If in that location was still no response for the boosted information, so this aspect of the study was excluded from the data synthesis.

Risk of bias assessment

Included studies were assessed for risk of bias by two independent raters (B.J.F.D. and M.Yard.) using the Cochrane Collaboration'south tool for assessing hazard of bias in randomised trials ¹². This followed the description in the Cochrane Handbook for Systematic Review of Interventions, version 5.1 (Part 2: 8.5.1) ¹². Any disagreements between ratings were resolved by discussion between the raters. A third party (J.C.R.W.) was bachelor in any case where disagreements persisted after give-and-take.

Data analysis

Descriptive analysis was performed for all demographic, intervention and effect data to facilitate narrative interpretation and comparison across studies. It was decided that a direct-comparing meta-analysis would simply be performed if data was available for similar time-points, outcomes and interventions across two or more than studies. As this was not possible with the identified studies, we conducted a narrative synthesis of the results based on the domains of involvement.

Results

A full of 158 studies were identified past the search, after duplicates were removed. After screening by full-text, six studies were identified as eligible for inclusion ( Figure 1). Of these, three were randomized controlled trials (RCTs), and three were retrospective comparative case series. The number of studies identified and excluded at each stage is detailed in Effigy 1.

Figure i.

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PRISMA flow diagram.

Study characteristics of the included trials including the interventions and comparators are provided in Table 1. Of the iii randomised controlled trials, 2 assessed the outcomes of different rehabilitation regimes in patients who had been exclusively treated with surgery ^{13, 14}. The remaining RCT assessed the consequence in patients managed both surgically and non-surgically, who were randomised to handling with either a plaster bandage or a functional splint ^xv. All three retrospective comparative instance serial compared different surgical techniques in patients exclusively managed surgically ^{16– 18}. Table 2 details the basic demographics of the intervention and comparator groups, as well as the details near the outcome information provided. The total details of all included studies and the forest plots are included inside the supplementary material ( Supplementary File 3– Supplementary File xv).

Table i.

Study characteristics.

Author	Yr	Periodical	Setting	Population	Type of study	Intervention	Comparator	Primary outcome	Outcomes	Time points
Crowley et al. ¹³	2013	Techniques in Paw and Upper Extremity Surgery	Hospital plastic surgery department	Acute complete UCL ruptures repaired with Mitek anchors	Randomised controlled trial	Early active mobilisation	Plaster immobilisation	None specified	Range of move, return to work, normal hand role, complications	ane month, iii months, 6 months
Katolik et al. ¹⁶	2008	Plastic and Reconstructive Surgery	Hand Surgery Unit	Acute consummate UCL ruptures treated with surgery	Retrospective comparative instance series	Os ballast repair	Pull out suture repair	None specified	Range of motion, Pinch strength, patient satisfaction, complication	Final follow up
Lane ¹⁷	1991	American Journal of Sports Medicine	Orthopaedic Surgery Department	Acute complete UCL ruptures treated with surgery	Retrospective comparative case series	Suture repair ('new method')	Pull out suture and Thousand wire stabilisation of MCPJ	None specified	Range of motion, strength (full vs partial), overall upshot (excellent vs good), complications	Final follow up
Rocchi et al. ¹⁴	2014	European Periodical of Physical and Rehabiliation Medicine	Orthopaedic Hand Surgery Department	Acute complete UCL ruptures treated with surgery	Randomised Controlled Trial	New spica	Standard spica	None specified	Range of movement, Dreiser index, VAS, Tip compression force, Complications	1 month, ii months, 6 months, 12 months
Saetta et al. ¹⁸	1992	Journal of Hand Surgery – British volume	Accident and Emergency Section	Acute complete UCL ruptures treated with surgery	Retrospective comparative example serial	Suture repair	Steel wire repair	None specified	Central strength, Pinch strength, Grasp strength, Functional outcome (excellent vs not)	Concluding follow up
Sollerman et al. ¹⁵	1991	Acta Orthopaedica Scandinavica	Manus Surgery Section	Astute UCL ruptures treated surgically/ non surgically	Randomised Controlled Trial	Functional splint	Plaster cast	None specified	Range of motion, Pinch grip strength, Sick leave	Final follow up

Tabular array 2.

Details of report participants demographics, inclusion/exclusion criteria and whether data was provided.

Author	Year	Inclusion criteria	Exclusion criteria	Intervention group age, years	Comparator group historic period, years	Intervention group sex activity	Comparator grouping sexual activity	Data comments
Crowley et al. ¹³	2013	All patients undergoing surgery for UCL rupture – diagnostic criteria not specified	K wire used in surgery	26 (range xx–43)	50 (range 37–72)	4 male, two female	4 male, 2 female person	All data other than complexity rate non available co-ordinate to author response
Katolik et al. ¹⁶	2008	<4 weeks onetime, laxity >30° in 30° flexion or >ten increased laxity compared to contralateral side	Avulsion fractures >10% of articulation surface	32	32	Non reported	Non reported	All data other than complication charge per unit not fully reported and author responded to confirm not available
Lane ¹⁷	1991	Grade 3 UCL ruptures – >35° laxity in thirty° flexion or >15° laxity relative to contralateral side		Non reported	Not reported	Non reported	Non reported	Outcome data complete and unable to contact author for full demographic data
Rocchi et al. ^xiv	2014	>30° laxity or >20° laxity relative to contralateral side	Partial tears, associated tendon/ neurovascular injury	Non reported	Not reported	Not reported	Not reported	Outcome information complete
Saetta et al. ¹⁸	1992	Unstable MCPJ but specifics not mentioned		Not reported	Not reported	Not reported	Not reported	Outcome data incomplete and author not contactable
Sollerman et al. ¹⁵	1991	Clinical and radiographic assessment but specifics not mentioned		Not reported	Not reported	Not reported	Not reported	Effect data incomplete and author non contactable

The study by Sollerman et al. ¹⁵ compared a functional splint with plaster cast treatment in patients with complete UCL ruptures; patients were managed both surgically and non surgically. The authors reported no divergence in MCPJ range of movement (ROM), grip force and sick leave taken; however, the data provided were insufficient for whatever further analysis, such as a forest plot.

The RCT by Rocchi et al. compared the outcomes of operated patients treated with either a traditional standard pollex spica which immobilized the MCPJ or a new modified pollex spica which allowed early MCP motion ¹⁴. At 12 months the new spica grouping had increased MCPJ ROM (standardized mean difference (SMD), −3.69; 95% confidence interval (CI), −two.46–−4.92, P<0.0001), a ameliorate Dreiser index (SMD, ane.65; 95%CI, 0.81–2.50; P=0.0001) and reduced hurting VAS (SMD, 1.53; 95% CI, 0.lxx–2.35; P=0.0003). There was no statistically meaning departure between groups in tip pinch strength at whatsoever time indicate. The RCT by Crowley et al. compared outcomes between patients treated with early on active mobilization or plaster immobilization after being treated surgically with Mitek anchor repair ^thirteen. The consequence data was not provided, meaning that any further assay was not possible.

The retrospective comparative case series past Saetta et al. demonstrated a higher chance of an excellent functional result with suture repair versus steel wire, but this was non statistically pregnant (risk ratio, ane.19; 95% CI, 0.82–1.71); the other outcome data was incomplete and thus precluded farther analysis. The retrospective case series by Lane demonstrated no statistically meaning difference in the chances of a full versus fractional recovery in ROM of the MCPJ, of a full versus partial recovery in strength and of a total versus partial functional recovery ¹⁷. The study by Katolik et al. did non provide adequate information with which to conduct any further assay ¹⁶.

Adverse events

Rocchi et al ¹⁴ . demonstrated no statistically pregnant departure in complication rate between treatment with the standard spica and the new spica (risk ratio, one.5; 95% CI, 0.29–7.73); the complications consisted of three cases of temporary dysaesthesia and two cases of inflammatory scars. The complication rate was identical in both the early on active mobilization and plaster cast groups in the study by Crowley et al ¹³ . (Chance ratio: 1.0, 95% CI: 0.32, 3.10); all half dozen complications in this study were that of scar tethering, with all resolving with ultrasound therapy and massage. The studies by Saetta et al. ¹⁷ and Sollerman et al. ¹⁸ did not make any mention of specific complications. Lane ¹⁷ demonstrated no statistically meaning difference in the complexity charge per unit betwixt the older method of pull out suture plus K-wire fixation and the new method of suture repair (take a chance ratio, iii.57; 95% CI, 0.25–50.xv); there was 1 complication with the traditional method (broken pull-out suture at 2 weeks) and i with the new method (re-rupture at 9 months) The study by Katolik et al ^sixteen . demonstrated a college complication rate with pull-out suture versus os anchor repair, but this was non statistically pregnant (adventure ratio, 4.00; 95% CI, 0.92–17.30); all the ten complications were soft-tissue-related (v were persistent wound erythema consistent with wound infection and 5 were paraesthesiae, which resolved over time).

Risk of bias

All criteria were judged as depression, high or unclear risk of bias. Overall, all studies were deemed to be at a high gamble of bias, particularly in terms of blinding of upshot assessment and selecting reporting. Full risk of bias assessment is available in Figure 2 and Effigy 3.

Figure 2.

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Take chances of bias graph.

Figure 3.

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Risk of bias summary.

Meta analysis

Every bit a issue of the degree of heterogeneity in terms of written report interventions and the incomplete result data, information technology was adamant that a meta-analysis of the outcomes was not possible. We carried out a meta-analysis of the complications of pull-out suture versus bone anchor, as two studies had compared these different surgical techniques ^{16, 17}. The complication rate of pull out suture fixation was higher than that of bone ballast repair (risk ratio, 3.92; 95% CI, ane.07–xiv.32; P=0.04). Although suggesting a higher rate of complexity, this should be interpreted with caution due to the high run a risk of bias in the included studes, reducing the reliability of the data and subsequent meta-analysis.

Discussion

The central finding of this systematic review is that is that no study exists comparing non-operative to surgical intervention in the treatment of consummate ruptures of the UCL of the thumb. The merely studies which take compared interventions are at high adventure of bias, specially in the areas of blinding of outcome assessment and selective consequence reporting. There is weak evidence to advise that early mobilisation of the thumb MCPJ may be benign following surgical repair. There is weak evidence that the pull out suture fixation has a higher rate of agin events when compared to bone anchor repair.

A systematic review by Samora et al. summarised the outcomes after both non-operative and operative handling of complete UCL ruptures ^nineteen. They found that the vast bulk of the evidence base was depression quality retrospective instance series and that just a small minority of patients were treated non-operatively. It was too shown that in that location was no significant difference in outcome between repair of acute injury and reconstruction after chronic injury.

Landsman et al. demonstrated generally good results when managing complete ruptures with splintage with only 15% failing this authorities not operative treatment ⁴; notably, 30% of the patients in this serial had displaced fractures and all patients had more than xxx° laxity in 30° of MCPJ flexion. A instance series reported past Pichora et al. also demonstrated generally satisfactory functional results with functional bracing, fifty-fifty in the 5 patients who were judged to accept sustained true Stener lesions ²⁰; notably, the three patients who failed functional bracing could not be predicted past the initial clinical tests. Case series purely relating to avulsion fractures of the UCL have shown contrasting results. For example Kuz et al. ²¹ demonstrated satisfactory outcomes in all patients only a non spousal relationship rate of 25%, this contrasts with the results of Dinowitz et al. ²², which demonstrated poor functional results in patients treated not-operatively for minimally displaced fractures.

At that place is a widely varying rate of Stener lesions in the literature, it being as low every bit 12% in the serial by Pichora et al. ^twenty and as loftier equally 70% in other series ²¹. The reasons underlying the variability in the rate of the Stener lesion are likely multiple and complex. Ane aspect of this conundrum appears to be the articulate bug with the reliability and accuracy of the radiological diagnosis of the Stener lesion, peculiarly relating to MRI ³. Although there are some high quality studies describing the reliability of ultrasound, at that place are no high quality studies relating to MRI ³. Mahajan et al. demonstrated excellent agreement betwixt radiologists in determining whether the UCL had completely ruptured; nonetheless, the presence or absenteeism of a Stener lesion was not assessed radiologically ^vi. Milner et al. take recently argued that whatever deportation of greater than iii mm (form iii past their system) should be treated operatively, owing to the observed high chance that these patients will fail with not operative treatment ⁹.

The recent report by Stoop et al. assessed 383 UCL injuries treated at iii different hospitals in a singe American urban center ¹¹. In full, 30% of cases were avulsion fractures and eleven% of cases were investigated with an MRI browse. Certain patient characteristics were associated with a higher charge per unit of operative intervention, for case greater historic period and more than displaced fractures. However some factors which were unrelated to patient characteristics were predictive of operative intervention, such every bit having an MRI and being treated by certain surgeons. It was felt that because the preoperative diagnosis of a Stener lesion has limited reliability and accuracy, the rates of surgery may vary based on surgeon beliefs, preferences and values.They also stated that "some surgeons believe some not-Stener injuries do good from operative handling" ^xi.

This review has demonstrated that all six studies of an intervention with a comparator in UCL treatment are at loftier adventure of bias. The blinding of participants would clearly not be possible in a trial of surgery versus non operative treatment; nonetheless, it is a recurrent theme that outcomes were assessed by non-blinded assessors (frequently the treating surgeon), which significantly increases the chance that detection bias will influence patient outcomes. None of the RCTs published a trial protocol with a specified principal outcome, while only the study by Rocchi et al. ^xiv used validated patient-reported outcome measures (Dreiser alphabetize and VAS). At that place was too a failure to fairly study all outcomes, with just one written report reporting adequate data for all outcomes to permit further analysis. None of the three RCTs included a power calculation. While the retrospective nature of the comparative case series introduces several potential sources of bias which may take influenced these results.

Conclusions

In that location is no prospective randomised or observational evidence to support operative intervention compared to non-operative treatment for acute complete ruptures of the ulnar collateral ligament of the thumb. There is weak bear witness to suggest that early mobilisation may be benign post-obit surgical repair. Further research is necessary in order to meliorate define which patients do good from which specific interventions.

Data availability

All data underlying the results are bachelor as part of the article and no additional source data are required.

Notes

[version 1; referees: 2 approved]

Funding Statement

J.C.R.W. is funded past the NIHR as an bookish clinical fellow.

The funders had no function in written report design, data collection and analysis, decision to publish, or preparation of the manuscript.

Supplementary textile

Supplementary File one. PRISMA checklist.

Supplementary File 2. Total search histories.

Supplementary File 3. Forest plot of Crowley et al. ^xiii chance ratio of adverse events.

Supplementary File 4. Woods plot of Katolik et al. ^xvi risk ratio of adverse events.

Supplementary File 5. Forest plot of Lane et al. ¹⁷ risk ratio of adverse events.

Supplementary File half dozen. Forest plot of Lane et al. ¹⁷ adventure ratio of full versus partial ROM.

Supplementary File 7. Forest plot of Lane et al. ¹⁷ run a risk ration of overall outcome full versus partial.

Supplementary File 8. Forest plot of Lane et al. ¹⁷ strength recovery total versus partial risk ratio.

Supplementary File 9. Wood plot of pull out suture versus anchor complication risk ratio.

Supplementary File 10. Forest plot of Rocchi et al. ^xiv risk ratio of agin events.

Supplementary File eleven. Forest plot of Rocchi et al. ¹⁴ Dreiser index.

Supplementary File 12. Wood plot of Rocchi et al. ¹⁴ Range of movement.

Supplementary File thirteen. Forest plot of Rocchi et al. ¹⁴ VAS.

Supplementary File xiv. Wood plot of Rocchi et al. ^xiv compression forcefulness.

Supplementary File 15. Woods plot of Saetta et al. ¹⁸ risk ratio of adverse events.

Supplementary File sixteen. RevMan five file containing the full data extracted from the studies.

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Referee response for version one

Charles Pailthorpe

ⁱRoyal Berkshire Hospital, Reading, United kingdom of great britain and northern ireland

¹Royal Berkshire Hospital, Reading, United kingdom

Competing interests: No competing interests were disclosed.

The authors aim was to perform a systematic review of the effectiveness of available interventions for acute complete rupture of the ulnar collateral ligament of the thumb in terms of patient-reported outcome measures and to assess the rates of adverse outcomes associated with these interventions.

Their methodology appears overall sound, withal I have some concerns over their request for boosted information from the authors of the selected papers. If this data was not included in the original papers how tin can it be accustomed retrospectively.
Overall the authors have achieved their aim of the systematic review even so they take added a large amount of extra information particularly concerning diagnosis (MRI and US).

In full general I think the newspaper has merit to be published merely in their stated aim the authors should include that they reviewed the literature concerning diagnosis as well.

11th June 2022: The status of this report has been updated from 'Approved with reservations' to 'Approved' in response to the author comments.

I thank the authors for their comments and take that no additional information was either sourced or utilised. Also, I take their comments on the diagnostic component in the article and accept that on rest it is useful in its contribution to the overall aim.

I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Referee response for version 1

Harpal Uppal

¹Lister Hospital, Stevenage, UK

²East and North Hertfordshire NHS Trust, Hertfordshire, United kingdom

^aneLister Hospital, Stevenage, Uk

²Eastward and North Hertfordshire NHS Trust, Hertfordshire, UK

Competing interests: No competing interests were disclosed.

This interesting article systematically reviews the literature base regarding injuries of the thumb ulnar collateral ligament. A large number of studies (158) were read and assessed to identify 6 eligible comparative studies. The 6 studies in question appear to exist highly heterogeneous and take a high risk of existence susceptible to bias.

The quality of published data is likewise poor for the written report to accomplish its initial goal of performing a meta assay. This is in itself a valuable slice of information which can be used to help drive further research.

The search strategy is well described and repeatable and conducted co-ordinate to the PRISMA checklist.

Overall this is a well written paper, of publishable standard, describing poor quality data which is of particular value to researchers planning new studies investigating or designing new studies concerning the ulnar collateral ligament.

I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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