Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow

Abstract

Injuries to the medial ulnar collateral ligament (MUCL can be devastating in overhead and throwing athletes. Prior to 1986 injury to this ligament was considered to be career ending. In that year, Dr. Frank Jobe reported on his initial experiences with reconstruction of the MUCL. His first case was pitcher Tommy John, who underwent what at that point was considered an experimental surgery to reconstruct the ligament using the palmaris longus tendon. The success of the classic “Tommy John” surgery in professional athletes has led most of these injuries to be managed by the same reconstructive technique. However, the injuries in young athletes do not appear to be the same as those sustained by professionals; one of the issues that led Dr. Jobe to utilize a reconstruction rather than a repair was the “wear and tear” of repetitive micro-trauma rather than a discrete area of injury. Fortunately in young, active athletes, the initial injury often is isolated to a single area, increasing the chance of both nonoperative and direct repair each being successful in allowing a return to sport. Unfortunately, there has been little focus on alternative treatment options in these young, nonprofessional athletes who continue to have instability despite conservative treatment and who wish to continue in sports. Many of these young athletes may have MUCL injuries isolated to one area in the proximal or distal end of the ligament that would seemingly allow a repair rather than reconstruction. Rather than extrapolate the data from professional athletes that the classic “Tommy John” operation is necessary for all of these young athletes to return to sports, we developed a protocol of repair in these players in which the ligament had a single area of injury on either the proximal end, distal end, or both in an attempt to minimize morbidity and loss of time and allow a more rapid return to sports. The indications for repair include a repairable injury (i.e., an injury to the ligament confined to the proximal or distal end of the ligament with or without a small fragment of bone) and a patient who desires to continue his throwing activity. In our initial study, 93 % (56 of 60) of these young (age range 13–23, avg. 16) athletes in the study returned to sports within 6 months (range 4–11.7 months) postoperatively at the same or higher level of competition.

Repair of MUCL remains a viable and most likely underused option in the management of MUCL injuries in these young athletes. Reports have shown excellent results and return to play in athletes. We recommend primary repair of MUCL for patients participating at the college level of play or younger if the damage is at one or both ends and if the rest of the ligament is normal to magnetic resonance angiogram (MRA) testing and direct inspection. Our conclusion is that patients can obtain a favorable outcome after repair of proximal or distal ligament injuries with a more rapid return to competition when the appropriate patient is selected for primary repair of the MUCL.

Video Legends

Video 13.1 Elbow arthroscopy can be performed in the prone position prior to the open surgery. Once the diagnostic arthroscopy has been completed the shoulder can be internally rotated, placing the hand on the arm board to expose the medial side of the elbow for the open approach

Video 13.2 A 5 cm incision is made from the tip of the medial epicondyle distally in line with the flexor-pronator muscles

Video 13.3 The flexor-pronator fascia is exposed by blunt dissection, looking carefully for and protecting the medial ante-brachial cutaneous nerve which often crosses the surgical field in this area

Video 13.4 Once the flexor-pronator fascia is exposed it is split longitudinally, revealing the red muscle fibers which are then bluntly separated to expose the ligament

Video 13.5 Once the ligament has been exposed, its outer surface is inspected; an incision is then made along its anterior border to allow for complete inspection of the torn area and the undersurface of the ligament. Note the egress of fluid from the prior arthroscopy as the incision is made

Video 13.6 The ligament is evaluated completely on both the outer and undersurface to confirm suitability for repair. If additional areas of damage are noted the repair is abandoned and a reconstruction performed

Video 13.7 Once the double loaded anchor is placed into the origin site of the humerus the first of 2 sets of sutures are individually passed in mattress fashion through the ligament. Note the blunt retractor carefully protecting the ulnar nerve, which lies adjacent to the ligament

Video 13.8 Placement of the first set of sutures is checked to insure they will repair the ligament anatomically and are in good tissue

Video 13.9 A second set of sutures is passed in mattress fashion more distally through the ligament as a backup to the primary repair

Video 13.10 The suture sets are tied sequentially. We usually tie the distal one first to take tension off the primary repair stitch

Video 13.11 Once the repair is completed the range of motion is tested. The small incision anterior to the ligament can be closed and motion and stability re-assessed by manual testing and, if necessary, repeat arthroscopy