Ulnar Collateral Ligament Reconstruction

Joshua S. Dines, MD

David W. Altchek, MD

Dr. Dines or an immediate family member has received royalties from Linvatec; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc.; serves as a paid consultant to or is an employee of Arthrex, Inc. and Trice; has received research or institutional support from Arthrex, Inc.; and serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons. Neither Dr. Altchek 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.

INTRODUCTION

Injury to the elbow ulnar collateral ligament (UCL) in overhead athletes can be career ending. This ligament, which is composed of an anterior, posterior, and transverse bundle, originates at the inferior surface of the medial epicondyle of the humerus and inserts onto the sublime tubercle of the ulna. It is the anterior bundle that serves as the primary restraint to valgus forces of up to 290 N and angular velocities exceeding 3,100°/s that occur during the throwing of a baseball. Each pitch actually approaches the ultimate tensile strength of the ligament, so it is not surprising that repetitive throwing can cause microtrauma and, eventually, complete failure of the ligament.

Prior to Jobe et al¹ describing a technique for ligament reconstruction that successfully returned athletes to the previous level of play, there were no surgical options for UCL injuries. The technique of Jobe et al¹ involved submuscular transposition of the ulnar nerve, elevation of the flexor-pronator mass to expose the tunnel sites, and a figure-of-8 graft configuration through a tunnel on the ulnar side and three large holes in the medial epicondyle (Figure 1, A). Since this initial report, alternative reconstruction methods have been described, including the docking technique (Figure 1, B), interference screw fixation techniques, and the hybrid DANE TJ technique²^,³^,⁴ (Figure 1, C).

The docking technique is performed through a muscle-splitting approach; instead of three large holes on the humeral side, a single bony tunnel with two small converging holes is used. We believe that this simplifies graft tensioning and decreases the risk of medial epicondyle fracture.²^,⁵ Additionally, arthroscopic evaluation of the elbow joint is used frequently in conjunction with the reconstruction, and the ulnar nerve is not routinely transposed.

At this point, most techniques for surgical reconstruction of the UCL reliably return athletes to their previous level of competition between 80% and 90% of the time.⁴^,⁵^,⁶^,⁷

PATIENT SELECTION

Indications

Reconstruction is indicated in patients with medial-side elbow pain consistent with UCL insufficiency that prevents them from competing at their normal level. Although a complete discussion of the evaluation of medial elbow pain in an athlete is beyond the scope of this chapter, it is important to start with a thorough history. Athletes may report chronic medial-side pain or, less frequently, an acute event. The surgeon must ask about the location of the pain as well as the presence or absence of ulnar nerve symptoms.

During the physical examination, to diagnose UCL pathology, we routinely perform a valgus stress test (noting the presence of both pain and/or instability), the moving valgus stress test, and the milking maneuver. The surgeon should check for the presence of a palmaris longus tendon as a potential graft source. Imaging studies complement the history and physical examination. Radiographs may show calcification in the ligament, bone spurs, or avulsion fractures (Figure 2). MRI often confirms the diagnosis of UCL insufficiency and can identify associated injuries, such as flexor-pronator tears, loose bodies, and cartilage injury (Figure 3).

When indicated, our preference is to use the docking technique, given its excellent clinical track record and the technical benefits mentioned previously.⁵^,⁷

Contraindications

In one published study on nonsurgical treatment of UCL injuries, only 42% of the athletes returned to their previous level of play.⁸ The use of biologics to augment conservative treatment has provided slightly improved outcomes, particularly in partial tears. That said, in patients with physical examination and imaging findings consistent with complete tears of the UCL and those who have failed conservative treatment, surgical reconstruction provides the most predictable outcome. However, if the athlete has no plans or options to continue playing the sport that bothers the elbow, surgery is usually not indicated. An example of this
is the high school senior pitcher who is not good enough to play in college. In situations like this, a change of position to one less stressful on the elbow (eg, from pitcher to first base or designated hitter) often allows the athlete to finish
the season without surgery. Additionally, a successful outcome after surgery requires a lengthy course of rehabilitation. If patients are unwilling or unable to complete this year of therapy, surgery is contraindicated.

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