Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Repair

Blake K. Montgomery, MD

Jeffrey Yao, MD

Dr. Yao or an immediate family member has received royalties from Arthrex, Inc.; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc. and Trimed; has stock or stock options held in 3D Systems, Elevate Braces, and McGinley Orthopedics; serves as a board member, owner, officer, or committee member of the American Association of Hand Surgery, the American Society for Surgery of the Hand, and the Arthroscopy Association of North America. Neither Dr. Montgomery nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

PATIENT SELECTION

Indications

Thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) injuries are common in an active population. Many of these injuries may be treated nonsurgically in a cast for 4 weeks. A thorough physical examination is critical to determine if there is an indication for surgery. Indications for repair or reconstruction of the thumb UCL include complete injury to the UCL (grade-3 ligamentous injury) as evidenced by instability to radial deviation stress testing with no firm end point, more than 30° of deviation with radial stress or more than 15° to 20° of deviation with radial stress compared with the contralateral side, presence of a Stener lesion (adductor aponeurosis interposition blocking reduction of the ulnar collateral ligament), or if the patient has failed nonsurgical treatment¹ (Video 51.1, Figures 1 and 2). Additionally, some surgeons include displaced avulsion fractures as an indication for surgery; however, this indication remains controversial.¹^,² Our preference is to treat these injuries nonsurgically unless there is concomitant instability. Historically, acute unstable injuries (“skier’s thumb”; injury less than 8 weeks old) have been treated with primary repair, while chronic injuries (“gamekeeper’s thumb”; injury greater than 8 weeks old) have been treated with reconstruction with or without tendon autograft, but recent studies have found promising results for primary repair for even chronic injuries.³^,⁴

FIGURE 1 Illustration of a Stener lesion. Adductor aponeurosis prevents avulsed UCL from reaching the UCL insertion on the proximal phalanx.

FIGURE 2 Illustration showing radial deviation instability. Examiner provides radial stress onto MCP joint, causing radial deviation beyond 30°.

VIDEO 51.1 Radial Deviation Instability. Preoperative examination of a patient with ulnar collateral ligament injury demonstrating more than 30° radial deviation at MCP joint with radial stress. Blake K. Montgomery, MD; Jeffrey Yao, MD (5 s)

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Video 51.1

Contraindications

There are few contraindications to repair or reconstruction of the ulnar collateral ligament of the thumb. The patient’s general health and risks of undergoing anesthesia should be assessed. Articular cartilage changes or frank osteoarthritis of the MCP joint, which may be seen in the setting of chronic UCL tears, is a contraindication, and if present, MCP arthrodesis should be considered.⁵

FIGURE 3 Preoperative radiographs. A and B, AP and lateral radiographs of a right thumb with ulnar collateral ligament injury.

PREOPERATIVE (DIAGNOSTIC) IMAGING

Prior to thumb ulnar collateral ligament repair or reconstruction, preoperative plain radiographs should be obtained. Three views of the thumb are obtained to evaluate for any joint subluxation or deformity, to rule out any fracture, and to evaluate for signs of arthritis (Figure 3). If the examiner is unable to determine if the UCL is completely torn or unable to determine if a Stener lesion is present on physical examination, then an MRI or an ultrasonography may be considered⁶^,⁷ (Figure 2). Fluoroscopy stress views of both thumbs can be obtained and compared. Stress views are a reliable way to quickly demonstrate instability at relatively low cost⁸ (Figure 4).

PROCEDURE

Multiple techniques exist for the surgical repair of the thumb MCP ulnar collateral ligament.⁴^,⁹^,¹⁰^,¹¹ One of the newer repair techniques involves suture tape (“internal brace”) augmentation, which may allow earlier return to activities and greater strength in comparison with conventional repair.¹⁰^,¹² The authors’ preferred method for repair is fixation using suture anchor(s) inserted into the ulnar base of the proximal phalanx from which the UCL typically avulses. Very rarely, the ligament may avulse from the head of the metacarpal.¹³ For our athletes or high-demand patients who cannot tolerate a long recovery period, we have used the internal brace technology with excellent results to date.

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