50
Medial Elbow Ligament Instability Surgery in Athletes
The ulnar collateral ligament (UCL) forms the primary soft tissue constraint of the elbow joint to valgus stress and consists of three parts: the anterior and posterior bundles and the transverse ligament. The anterior bundle is the primary stabilizing structure to valgus stress. It originates from the anteroinferior surface of the medial epicondyle of the humerus posterior to the axis of rotation and inserts on the sublime tubercle of the ulna (Fig. 50–1).
Indications
Injuries to the UCL of the elbow are relatively common in throwing or overhead athletes. Injuries result from either acute traumatic or repeated valgus stress to the elbow. Repeated valgus stress can cause attenuation or rupture of the UCL and result in medial elbow instability. This results in functional pain in the medial aspect of the elbow when throwing overhead. Injuries can occur in the origin, midsubstance, or insertion of the ligament and may be partial or complete. Important points on the history and physical examination when evaluating an overhead athlete with medial elbow pain are:
1. History of previous medial elbow pain
2. Duration and severity of symptoms
3. Phase of the throwing cycle when the pain occurs
4. Pain with any activities other than throwing
5. Presence or absence of ulnar nerve symptoms
6. Location of pain
7. Presence or absence of medial elbow swelling (if injury is acute)
8. Reproduction of the medial elbow pain with valgus stress
9. Presence or absence of valgus instability
An injury to the UCL in a throwing or overhead athlete can significantly impair their performance. All patients should have a trial of conservative treatment of rest, immobilization, and nonsteroidal anti-inflammatory drugs. If they fail this trial, a reconstruction of the UCL needs to be performed for the athlete to return to their previous level of performance.
Radiographic Evaluation
Every athlete with medial elbow pain should have plain X-rays of the elbow. These will reveal olecranon osteophytes, calcifications of the ligament (if the injury is chronic), and bony avulsions. A valgus stress view can be obtained but its effectiveness and accuracy have been questioned. Magnetic resonance imaging (MRI) can provide useful information in the overhead athlete with medial elbow pain. MRI with 3 mm cuts and a gradient echo sequence offer the best visualization of the ligament. With MRI, you are able to evaluate the articular surfaces as well.
Historical Review
Several techniques for UCL reconstruction have been described in the literature. The classic technique is that described by Jobe et al. Modifications of this technique have been made, including splitting rather than detaching the common flexor mass and subcutaneous rather than submuscular ulnar nerve transposition.
Jobe et al reported the first large series on reconstruction of the UCL in throwing athletes. The technique involved reconstruction of the UCL with a free tendon graft, usually the palmaris longus. The exposure included division of the flexor-pronator mass and elevation of the medial epicondyle for exposure. The tendon graft was secured in the humerus and ulna through bone tunnels in a figure-of-eight fashion. Transfer of the ulnar nerve was performed in all patients. The results of this technique have been reported by several authors. Results reported in the literature have been good, but complications have involved ulnar nerve symptoms and extended return to throwing. Return to competition at the preinjury level occurs approximately 75% of the time following reconstruction and is somewhat lower when a direct repair is performed. The poorer results from direct repair are probably from failure to recognize the presence of under-surface tearing of the ligament at the time of surgery. Postoperative ulnar neuropathy has been the most common complication, with an incidence as high as 31%. We describe a technique of ulnar collateral ligament reconstruction using a minimally invasive muscle-splitting approach, described by Smith et al. The graft is fixed in a bony trough on the humeral side with two bioabsorbable suture anchors and through standard bony tunnels in the ulna at the UCL insertion. No transposition of the ulnar nerve is required and the flexor-pronator origin is left intact.
Surgical Approach
The patient is positioned in the supine position on the operating room table with a hand table attachment on the affected side.
Graft
1. Prior to surgery, the presence or absence of a palmaris longus is documented in each wrist. If there is a palmaris longus, we prefer to use it for our reconstruction. If there is no palmaris longus, then we use either a plantaris tendon or a strip of Achilles tendon.
2. The palmaris longus tendon is harvested through three to four small transverse incisions on the volar aspect of the forearm. Care is taken not to disturb the nearby neurovascular structures.
3. Once the tendon is harvested, the wounds are closed with 4–0 nylon horizontal mattress stitches. The tendon is prepared for passage through the ulnar tunnels with 2–0 dyed nonabsorbable sutures (one white, one green) on each end.
Approach and Technique
1. The reconstruction is performed through a muscle-splitting approach originally described by Smith et al. The medial epicondyle, joint line, and ulnar nerve are marked. It is extremely importantto document the presence of subluxation of the ulnar nerve to avoid iatrogenic injury.
2. The arm is exsanguinated and the tourniquet inflated to 250 mm Hg. A 6 cm incision is made beginning just distal to the level of the medial epicondyle and is brought slightly volar (Fig. 50–2).
3. The one to two branches of the medial antebrachial cutaneous nerve are identified and protected throughout the procedure to avoid painful neuroma and paresthesias postoperatively (Fig. 50–2).
4. Dissection is carried to the fascia overlying the flexor-pronator muscles. A split in the fascia is made in the posterior third (Fig. 50–2), and careful blunt dissection is performed with two freer elevators splitting the muscle in line with its fibers.
5. Once the split is made, the underlying joint capsule and UCL are identified. A valgus stress test at this point will confirm the laxity in the UCL. If there is a complete rupture of the ligament, it can be identified at this point. More commonly the ligament is grossly intact but nonfunctional.
6. The anterior and posterior aspects of the anterior bundle of the ligament are identified easily with valgus stress. A longitudinal split is made at the anterior and posterior aspects of the anterior bundle, entering into the joint space.
7. The ligament is then divided in an oblique manner leaving a portion for reinforcement at the end of the reconstruction. The area of injury of the ligament is identified and documented and is removed by sharp dissection. It is extremely important to leave the proximal origin of the ligament intact if it is not damaged (Fig. 50–3).
8. The joint space is identified and care is taken not to disturb the articular cartilage.
9. The humeral side is addressed first. The origin of the native ligament is identified. The site is debrided of inflammatory tissues down to bone.
10. A trough is created in the medial epicondyle in line with the ligament origin with a high-speed burr (Fig. 50–3).
11. Two bioabsorbable suture anchors are placed in the medial and lateral aspects of the trough. Care must be taken to guide the anchors in the proper plane with regard to the humeral shaft. The anchors rest within a bony trough so that the ligament will be recessed into the trough (Fig. 50–3).
12. Once the anchors are in place, it must be confirmed that the sutures slide through the eyelet in the anchor. If they do not slide, then the anchor was inserted too far and must be replaced with a larger anchor.
13. Once the humeral side is complete, the ulnar side needs to be addressed. The insertion of the native UCL on the sublime (coronoid) tubercle is identified (Fig. 50–3).
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
