“For more than 4 decades, reconstruction of the ulnar collateral ligament (UCL) using some type of autograft tissue has been the standard of care for UCL-injured athletes. This article reviews the history of UCL repair including the rationale for the revival of interest in primary repair of the UCL as an option for the treatment of select athletes as well as the early clinical results indicating the short-term successful outcomes of the procedure in properly selected athletes.”
In summary, primary repair of the ulnar collateral ligament (UCL) using InternalBrace augmentation seems to have a predictably high rate of clinical success in properly selected patients.
The ideal candidates for primary repair are generally younger athletes with high-grade avulsion type injuries of the proximal or distal portion of the ligament and without evidence of attritional or more diffuse ligament involvement.
Continued long-term follow-up is necessary, but short-term results are on par with the results for traditional UCL reconstruction techniques but with shorter return to play times.
The rise of ulnar collateral ligament reconstruction and the fall of ulnar collateral ligament repair
On July 25, 1974, Dr Frank Jobe performed the first ulnar collateral ligament (UCL) reconstruction on Los Angeles Dodgers pitcher Tommy John ( Fig. 1 ). The success of that surgery resulted in it being called the Tommy John procedure. Jobe and colleagues first reported his technique and initial results in 1986. Before he reported his groundbreaking technique and initial results, most patients with UCL tears were treated by repair of the native ligament. The first reported cases of repair of the UCL were by Norwood and colleagues, in 1981. In the small series of 4 patients, 4 of 4 patients regained full elbow motion and had no residual instability at 2 years after surgical repair but only 2 of 4 were able to return to full participation. None of the patients in the study were overhead athletes. Because of the poor outcomes with repair, injuries of the UCL were considered career ending before Jobe’s landmark technique.
Jobe’s original article described the surgical technique of reconstruction using a palmaris longus tendon autograft. He also described the postoperative rehabilitation protocol. Initial outcomes were reported in 16 throwing athletes, including the procedure’s namesake, Tommy John. Jobe reported good to excellent results in 10 of the 16 patients who returned to their previous level of participation in sports, one patient returned to a lower level of participation and 5 patients retired from professional athletics due to reasons not related to the UCL surgery. In 1992, Conway and colleagues reported on a larger series of 70 patients treated by Dr Jobe who had undergone UCL surgery between 1974 and 1987. In that series, 56 patients had undergone reconstruction using the Tommy John reconstruction technique and 14 patients had undergone direct repair of the ligament to bone without graft reconstruction. The investigators reported good to excellent results in 80% off the reconstructions and 71% of the repairs. However, only 50% of the patients undergoing repair returned to the same level of play as compared with 68% of patients with reconstructions who returned to the same level. Even more damning was the return to play among Major League Baseball (MLB) players, as only 29% of MLB players undergoing repair return to the same level of play compared with 75% of those with reconstructions. Similarly, Andrews and colleagest in 1995 and Azar and colleagues in 2000 also reported poor outcomes of primary repair of the UCL as compared with reconstruction, which effectively signaled the death of UCL repair. Reconstruction using the Tommy John technique became the standard of care for the next 2 decades.
Individualizing treatment of the ulnar collateral ligament–injured athlete
Since Dr Jobe’s 2 landmark publications, virtually all UCL-injured athletes had been treated with some form of UCL reconstruction regardless of injury pattern, player age, or level of participation. Although physicians attempted to individualize treatment based on factors such as player age, player level, position played, time of season when injury occurred, baseball career expectations, and other sports participation, treatment was not individualized based on the pattern of ligament injury. Despite the fact that clinicians recognized and sought to classify injury patterns as acute or chronic tears; partial or complete tears; high- or low-grade partial tears; or proximal, midsubstance or distal tears, the same surgical treatment option was applied to all tears, which is surgical reconstruction.
Researchers studying the success rates of nonsurgical treatment of different injury patterns noted that more distal tears, high-grade partial tears, and complete tears tended to do worse with nonoperative treatment and had a higher conversion rate to reconstruction.
Clinicians who frequently treated athletes with elbow UCL injuries began asking if perhaps reconstruction of the UCL was too much surgery for certain injury patterns. This gave rise to a reemerging interest in the possibility of primary repair of the UCL in certain injury patterns, specifically acute proximal or distal avulsion type injuries without chronic ligament changes.
Primary ulnar collateral ligament repair revisited
In 2006, Argo and colleagues reported on a series of 18 patients undergoing primary repair of the UCL using a variety of primary repair techniques. All patients were female athletes competing in a variety of sports. There were 14 softball players (1 pitcher), gymnasts, and tennis player. It was a relatively young group with mean age of 22 years (range, 15.1–37.2 years). The mean follow-up was 38.8 months (range, 12.4–68.6 months). Repair techniques include plication (n = 6), repair to bone using anchors (n = 11), or drill holes (n = 1). The mean Andrews and Carson Elbow Outcome Score increased from a preoperative score of 120 to 191 postoperatively ( P < .0001). Seventeen of eighteen athletes returned to their sport at a mean of 2.5 months postoperatively.
Two years later in 2008, Richard and colleagues reported on a series of 11 athletes undergoing repair of acute tears of the proximal portion of the UCL at an average of 20 days after injury. All 11 athletes had suffered acute rupture of the medial UCL via traumatic injury but had not sustained an elbow dislocation. Valgus instability was present in 11 of 11 athletes, and MRI scans confirmed complete avulsion of the proximal UCL in all cases. All patients also had avulsion of the flexor-pronator origin from the medial epicondyle. Nine of eleven patients underwent direct repair of the avulsed UCL to the footprint of the medial epicondyle using a suture repair technique and 2 of 11 underwent repair using suture anchors. The investigators reported good outcomes with 9 or 11 returning to collegiate athletics by 6 months postop.
Savoie and colleagues expanded on their initial work as reported by Argo and colleagues by reporting on a much larger series of athletes undergoing primary repair of the UCL. Their study cohort included 60 young throwing athletes (mean age 17.2 years) undergoing repair of proximal or distal UCL avulsion injuries in young throwing athletes. The surgical techniques include 9 repaired by suture through bone tunnels and 51 repaired using single-suture anchors. At an average follow-up of 59.2 months, the investigators reported that 58 of 60 athletes returned to sport at the same level or higher within 6 months. They again used the Andrews and Carson Elbow Outcome Score and reported an increase from a preoperative score of 132 to a postoperative score of 188 ( P < .0001). Good to excellent results were reported in 93% of patients and 58 of 60 were able to return to their same or higher level of sports participation by 6 months postoperatively. There were only 2 early failures.
These improved outcomes of primary repair of the UCL in select avulsion type injury patterns in young athletes served as the spark that reignited interest in the viability of UCL repair for a larger subset of UCL injured athletes. Combined with new technological advances in suture material and anchors, a repair revolution was about to take hold.
The role of the InternalBrace
Recent advances in technology have included the development of braided tapes and so-called super sutures as well as a plethora of nonmetallic and knotless suture anchors. One of these recent developments is the InternalBrace (Arthrex, Naples FL) ( Fig. 2 ), which is spanning suture tape anchored on each end and used to augment ligament repair. It is composed of a FiberTape (Arthrex, Naples, FL) and 2 BiocompositeSwiveLock anchors (Arthrex, Naples, FL). The concept of the InternalBrace was first conceived and clinically used by Professor Gordon Mackay of Scotland. , He initially reported favorable clinical results using the InternalBrace in the repair of lateral ligament injuries as an augment to the classic Brostrom procedure as well as in ligament repairs of the knee including the anterior cruciate ligament and medial collateral ligament. Biomechanical studies have validated the biomechanical advantages of internal bracing over primary repair using sutures or anchors alone.
Piggybacking off the initial clinical success of the InternalBrace in knee medial collateral ligament repair, Dugas and colleagues extended the application of the InternalBrace to a biomechanical study of its potential use in repair of the medial UCL of the elbow. In a cadaveric study using 9 matched pairs of cadaveric elbows, the researchers compared the biomechanical, time zero properties of augmented UCL repair with the typical modified Jobe technique for UCL reconstruction. Using a cyclical valgus rotational torque applied to the humerus followed by a torque to failure, the intact state was compared with the UCL insufficient state by creating a surgical lesion of the UCL. Each matched pair specimen then underwent either augmented UCL repair or reconstruction. Gap formation, torsional stiffness, and maximum torque at failure were measured. After the repair or reconstruction procedures, the repair group showed less gapping during cyclical testing than the reconstruction group. There was no difference between the 2 groups for torsional stiffness or maximum torque to failure. The investigators concluded that the time-zero failure properties of the augmented repair technique were at least with those of the traditional modified Jobe reconstruction technique even after 500 cycles of valgus loading.
Surgical technique of augmented repair of the ulnar collateral ligament
With the biomechanical study as a basis supporting the potential clinical application of augmented UCL repair, Dugas introduced a novel ligament repair technique using the InternalBrace. The goal of the technique was to restore valgus stability, decrease soft tissue dissection, preserve bone, and allow a faster return to play.
Ulnar Collateral Ligament Repair Technique
The current indications for primary repair of the UCL include younger patients (<age 25 years) with high-grade proximal or distal avulsion type injuries of the UCL without evidence of more diffuse ligament injury or attritional tearing.
A standard medial approach is used with an 8- to 10-cm incision extending distally from the medial epicondyle. Skin flaps are raised anteriorly and posteriorly, and any crossing superficial vessels are cauterized. The medial antebrachial cutaneous nerve and any of its branches are identified and preserved. The branches are usually found anterior and distal to the medial epicondyle and often cross the surgical field. Because muscle-splitting approach is used, the flexor-pronator mass is split between the anterior one-third and posterior two-thirds. There is often a raphe of the flexor carpe ulnaris fascia that can be identified and exploited for this muscle split. A periosteal elevator is used to split the muscle fibers and dissect down to the underlying UCL ( Fig. 3 ). In many cases, the superficial fibers of the ligament may seem entirely normal except in cases of acute, full-thickness tears that are treated very soon after initial injury ( Figs. 4 A, 4B). The UCL is incised longitudinally from the sublime tubercle to the medial epicondyle. This is done to allow exposure of the underlying joint, inspection of the deep fibers, identification of the tear, and assessment of the overall ligament quality. If the UCL has signs of diffuse or attritional disease, repair is abandoned and reconstruction is performed. If the ligament injury pattern matches the MRI findings and is consistent with a high-grade or complete avulsion type tear of the proximal or distal portion of the ligament and the remainder of the ligament seems grossly normal without attritional changes, then repair is undertaken. Once the ligament is incised and the patient is deemed to be a candidate for repair, the site of the ligament tear, proximal or distal, is identified. For distal tears, debridement of periosteum and soft tissue from footprint of the UCL at the sublime tubercle is undertaken. For proximal tears, debridement of any fibrous tissue at the medial epicondyle origin of the ligament is debrided. In either case, the ulnar nerve should be identified and protected, especially during drilling. The first 3.5-mm nonabsorbable suture anchor (SwiveLock, Arthrex, Naples, FL) is placed on the side of the ligament tear. For distal tears, the anatomic UCL origin on the sublime tubercle is drilled and tapped. For proximal tears, the center of the origin of the UCL at the medial epicondyle is drilled and tapped. This anchor is loaded with 2-mm FiberTape (Arthrex) that is collagen-coated and second high-tensile nonabsorbable suture. For distal tears, a #0 high-tensile nonabsorbable suture is used. For proximal tears, a #1 high-tensile nonabsorbable suture is used. After the first anchor is placed ( Fig. 5 ), the individual limbs of the high-tensile nonabsorbable suture are passed through the anterior and posterior limbs of the split ligament ( Fig. 6 ). The elbow is placed in 60° of flexion, and varus load is applied to close down the medial joint. The sutures are then tied, thereby repairing the native ligament directly to bone at the site of the avulsion. The longitudinal split in the ligament is repaired from distal to proximal with size 0 Vicryl suture placed in mattress fashion. These sutures should be passed using the needle from posterior limb of the ligament through the anterior to the ulna nerve. These sutures are left untied until after the InternalBrace has been tensioned and fixed.