CHAPTER 37 – Ulnar Collateral Ligament Reconstruction

Injury to the medial side of the elbow is common in overhead athletes, such as baseball pitchers, tennis players, and javelin throwers. The overhead throwing motion places a tremendous amount of valgus stress on the elbow that is resisted by the medial structures. The anterior bundle of the ulnar collateral ligament (UCL) has been demonstrated to be the primary restraint to valgus stress about the elbow.^[6] Repeated high valgus stresses imparted from the repetitive act of throwing can result in chronic attenuation or acute rupture of the UCL. In the throwing athlete, UCL insufficiency can be manifested as disabling elbow pain with the inability to compete effectively. Since the first description of UCL reconstruction in the landmark work of Jobe et al,^[8] there have been several modifications to the original technique. These modifications have attempted to reduce the amount of soft tissue dissection and the incidence of ulnar nerve complications and to provide more consistent and secure fixation. Constants in all described techniques include accurate diagnosis, appropriate selection of patients, anatomic reconstruction of the anterior bundle of the UCL, and maintenance of a specific rehabilitation program to allow the athlete to return successfully to sport.

Preoperative Considerations

History

The typical history in a throwing athlete with UCL injury is episodic medial elbow pain that prevents him or her from competing effectively. Pain is usually elicited in the early acceleration phase of throwing. Affected pitchers complain of loss of velocity or accuracy. On occasion, the athlete will sustain an acute injury with sudden onset of medial pain accompanied by a “pop” followed by an inability to continue throwing. Symptoms of ulnar nerve irritability, such as paresthesias, in the little and ring fingers may also be present.

Physical Examination

A thorough physical examination of the throwing athlete includes the following:

	•	Evaluation of the neck and entire upper extremity
	•	Direct assessment of the ulnar nerve for subluxation, irritability (presence of Tinel sign), and integrity of distal motor and sensory function in the hand
	•	Tenderness may be elicited over the UCL ligament slightly distal and posterior to the flexor-pronator muscle origin.

Several tests have been described to evaluate the integrity of the UCL:

	•	Manual valgus stress test performed at 30 degrees of elbow flexion
	•	“Milking maneuver”[16]
	•	Moving valgus stress test[10]

These tests may elicit medial elbow pain with valgus stress, or the examiner may appreciate medial joint line opening with stress especially in comparison with the contralateral elbow. Consideration of concurrent posteromedial impingement in the thrower’s elbow can be evaluated with the valgus extension overload test.^[2] If reconstruction of the UCL is considered, the presence of an ipsilateral or contralateral palmaris longus should be assessed.

Imaging

Radiography

•

Anteroposterior, lateral, and axial views of the elbow

Plain radiographs are inspected for loose bodies, evidence of degenerative changes such as posteromedial osteophytes of the olecranon, medial joint line spurring, and possible calcifications in the UCL indicative of a chronic injury.

Other Modalities

	•	Computed tomographic arthrography
	•	Magnetic resonance imaging

The senior author prefers magnetic resonance imaging as the imaging modality of choice for detailed characterization of the integrity of the UCL and evaluation of other soft tissue structures (
Fig. 37-1

).

Indications and Contraindications

The indication for UCL reconstruction in a throwing athlete is medial elbow pain associated with UCL insuffi ciency that prevents the athlete from competing effectively. Nonoperative treatment for elite throwing athletes is usually unsuccessful.^[12] Athletes who do not plan on returning to sport and those who are able to return to sport after rehabilitation and do not subject their elbows to repeated valgus stress are not generally considered candidates for reconstruction.^[4]

Surgical Planning

Concomitant procedures include ulnar nerve transposition based on preoperative symptoms suggestive of nerve irritability or subluxation. Findings of loose bodies, spurs, and posteromedial impingement can be addressed either arthroscopically or through an arthrotomy at the time of the reconstruction.

The initial graft choice is an ipsilateral palmaris longus tendon. If the tendon is not present in the patient, other choices are the contralateral palmaris longus tendon if it is present, gracilis or semitendinosus tendons, toe extensor, and allograft.

Surgical Technique

Anesthesia and Positioning

We prefer to perform the procedure under axillary block anesthesia, although on the basis of the surgeon’s, patient’s, and anesthesiologist’s preferences, general anesthesia or a combination of general and regional anesthesia can be used. The patient is placed supine on the operating table with the affected extremity abducted and placed on an attached hand table. A sterile or nonsterile pneumatic tourniquet is placed about the arm as proximal as possible for exposure. The arm is then prepared and draped in the usual sterile fashion.

Specific Steps (
Box 37-1

)

1. Exposure

The limb is exsanguinated, and the tourniquet is inflated. The medial epicondyle is identified, and an approximately 8- to 10-cm curvilinear incision is made centered over the medial epicondyle. During the exposure, care is taken to identify and to protect the branches of the medial antebrachial cutaneous nerve that cross the operative field. Injury to these nerves can result in either sensory loss along the medial aspect of the forearm or a painful neuroma. Dissection is carried down to the level of the forearm fascia and the flexor-pronator aponeurosis (
Fig. 37-2

). We prefer the muscle-splitting approach^[14] for exposure of the UCL. A fascial raphe can usually be identified in the flexor-pronator mass at the junction of the anterior two thirds and posterior third of the muscle group. This raphe represents an internervous plane between the median nerve–innervated palmaris longus and deeper flexor digitorum superficialis and the ulnar nerve–innervated flexor carpi ulnaris. The fascia is split through the raphe from the medial epicondyle to a point approximately 1 cm distal to the sublime tubercle. The sublime tubercle can be palpated deep under the flexor mass. More distal dissection risks denervation of the surrounding musculature from crossing nerve branches. The muscle is then bluntly divided down to the level of the underlying UCL (
Fig. 37-3

). Care is taken during the split and division of the muscle because the ulnar nerve lies just posterior to the approach. A blunt self-retainer is used to retract the musculature, and a small periosteal elevator can be used to clean any remaining muscle fibers from the UCL. Application of a valgus stress should reveal excessive medial joint line opening consistent with UCL insufficiency. After external inspection of the ligament, a longitudinal incision is made in the direction of its fibers to assess undersurface tears and degeneration. As much of the native, intact UCL is preserved as possible. Also through this incision, the joint can be inspected for loose bodies and other intraarticular disease.

Box 37-1 

Surgical Steps

1.    Exposure    2.    Harvest of palmaris longus graft    3.    Preparation of ulnar tunnels    4.    Preparation of humeral tunnels    5.    Passage and tensioning of the graft    6.    Closure

2. Graft Harvest

If it is present, the ipsilateral palmaris longus tendon is harvested as the preferred graft (
Fig. 37-4

). The tendon is identified at the level of the proximal wrist flexion crease as it inserts into the palmar fascia. A small 1- to 2-cm transverse incision is made directly over the tendon. A small hemostat is used to dissect the tendon, with care taken to protect the underlying median nerve. Tension is applied to the tendon with the hemostat, and two additional transverse incisions are made proximally over the tendon and myotendinous junction approximately 8 cm apart. The tendon graft is then incised proximally and distally and delivered out of the wound (
Fig. 37-5

). Ideally, the graft length is 12 to 15 cm. The graft is cleaned of muscle, and a running whipstitch is placed in both ends of the graft with No. 2 FiberWire (Arthrex, Inc., Naples, Fla).

3. Preparation of Ulnar Tunnels

With careful subperiosteal dissection, the medial aspect of the ulna distal to the sublime tubercle is exposed in preparation for the ulnar bone tunnels. By use of a 3.2-mm drill bit, two converging tunnels are made at right angles to each other anterior and posterior to the sublime tubercle, with care taken to maintain a good bone bridge of approximately 6 to 8 mm (
Fig. 37-6

). A small curved curet is used to clean the tunnel entrance of bone debris and to connect the tunnels.

4. Preparation of Humeral Tunnels

The insertion of the UCL is traced back to its origin on the medial epicondyle. The insertion is located on the anteroinferior surface of the epicondyle, usually in the middle two thirds of the epicondyle in the coronal plane.^[9] A 3.2-mm drill bit is used to make a bone tunnel starting at the insertion and through the back of the medial epicondyle (
Fig. 37-7

). The ulnar nerve is carefully protected during this portion to avoid iatrogenic injury from the drill. Next, a minimal release is performed to allow safe retraction of the nerve. The proximal portion of the epicondyle anterior to the medial intermuscular septum is then carefully exposed subperiostally. A 3.2-mm drill bit is used to make a second bone tunnel starting anterior to the medial intermuscular septum and aiming distally to approximately the middle portion of the previously drilled tunnel. Care is taken to maintain an adequate bone bridge of at least 5 mm between the tunnels and the trochlear articular surface. A small curved curet is then used to clean the tunnels of bone debris.

5. Passage and Tensioning of the Graft

The prepared graft is then passed from anterior to posterior in the ulnar tunnel with the help of a Hewson suture passer (
Fig. 37-8

). The graft is passed through the humeral tunnels in a figure-of-eight fashion with a three-ply reconstruction (
Fig. 37-9

). The elbow joint is then reduced with the application of a varus stress, and the elbow is flexed to approximately 45 degrees as tension is applied across the graft. The graft is then sutured to itself with No. 2 FiberWire in a mattress fashion (
Fig. 37-10

). The native UCL is also sutured to itself and to the graft to reinforce the reconstruction.

6. Closure

The tourniquet is deflated, and meticulous hemostasis is obtained to prevent a postoperative hematoma. The wound is thoroughly irrigated before closure. The flexor-pronator mass is closed with No. 0 Vicryl suture, followed by routine skin closure. A sterile dressing is applied, and the arm is splinted in approximately 90 degrees of flexion with the forearm in neutral rotation.

Postoperative Considerations

Follow-up

One week after surgery, the sutures are removed and a hinged elbow brace is applied.

Rehabilitation

A specific rehabilitation protocol is crucial to successful return to athletic competition.

	•	Motion is initially allowed only from 45 to 90 degrees and is gradually progressed in the brace so that full motion is obtained at approximately 6 weeks after surgery.
	•	Physical therapy is begun at 6 weeks with gradual strengthening of the shoulder and forearm musculature and correction of any losses of motion. Begin manual resisted exercises. Internal rotation exercises below shoulder level may begin.
	•	The brace is removed at 6 weeks after surgery, and wrist, elbow, and shoulder exercises are begun.
	•	At approximately 12 weeks, increased strength training is begun with a sport-specific rehabilitation program.
	•	Week 14: Begin modified throwing program on knees. Additional activities and exercises can be added.
	•	Weeks 15-28: For throwers, return to activity is initiated at approximately 15 weeks after surgery. Emphasis is placed on warm-up and a conditioning program. Phase 1 consists of an interval throwing program that is gradually progressed through week 28. The program begins with throws of 45 feet and progresses to long tossing up to 180 feet. Athletes throw every other day, with progress to the next phase allowed if they are free of pain. Pitchers perform the long-toss program to 120 feet before beginning interval throwing from off the mound. At week 28, pitchers can throw from the mound. Throwers ultimately return to competitive play at approximately week 52 or at the completion of their throwing program.

Complications

	•	Ulnar nerve irritation is the most common postoperative complication with a reported incidence of up to 21%.[7]
	•	Trauma to the medial antebrachial cutaneous nerve
	•	Hematoma
	•	Superficial or deep infection
	•	Fracture of the humeral or ulnar tunnels from an insufficient bone bridge

PEARLS AND PITFALLS

Pearls    •    The primary indication for surgery is the patient’s inability to throw without pain after rehabilitation. The decision for surgical treatment is not based on magnetic resonance imaging findings. The moving valgus stress test and the milking test are good prognosticators of injury to the ulnar collateral ligament.    •    If the examination reveals pain in the posterior compartment as it comes into terminal extension, the posterior osteophyte should be addressed.    •    The native ulnar collateral ligament should be repaired to itself first before the transferred tendon is sewn into the ligament to prevent extravasation of fluid from the joint and irritation of the tendon with flexion and extension.    •    In the absence of preoperative ulnar nerve symptoms, transfer of the nerve is not necessary. However, it should be identified during dissection so that it can be retracted during drilling of the humeral epicondyle. Pitfalls    •    In drilling the holes for the sublime tubercle of the ulna, take care to maintain a significant bone bridge to prevent fracture. When the curet is used, do not elevate it anteriorly because it could fracture the bone.    •    To avoid compressing the ulnar nerve when the flexor muscle tendon split is performed, do not use a retractor against the bone inferiorly.    •    The final repair should be performed with the elbow flexed, supinated, and in varus to ensure tightness of the transferred tendon.    •    During rehabilitation, the patient should be warned to avoid excessive valgus loading for 4 months after surgery.

Results

The results of UCL reconstruction are best measured by the athlete’s return to sport. Successful return to elite throwing is a far more stringent outcome measure than is objective testing of valgus laxity.^[13] Since the original description of the technique by Jobe, there have been several modifications to the technique to attempt to decrease morbidity and postoperative complications while allowing the athlete to safely return to sport (
Table 37-1

). Current techniques allow the competitive throwing athlete to return successfully to the same or higher level of sport approximately 79% to 92% of the time. Successful return also depends on completion of a dedicated prolonged rehabilitation protocol. Continued advances in technology, such as interference screw fixation^[1] and hybrid techniques, may allow an even greater chance of success in the future, but clinical validation is pending.

Author	Technique	Results
Jobe et al[8] (1986)	Original “Tommy John” method	10/16 (63%) throwing athletes returned to same level
	Flexor-pronator mass detached
	Figure-of-eight graft
	Submuscular ulnar nerve transposition
Conway et al[7] (1992)	Original method	38/56 (68%) athletes returned to same level
	Flexor-pronator mass detached	12/56 (21%) postoperative ulnar nerve irritability
	Figure-of-eight graft	Reconstruction better than repair
	Submuscular ulnar nerve transposition
Azar et al[3] (2000)	Andrews modification of original Jobe technique	78 UCL reconstructions; 41% professional
	Flexor mass divided with partial detachment of flexor carpi ulnaris	79% of athletes returned to same or higher level
	Figure-of-eight graft	Average return: 9.8 months
	Subcutaneous ulnar nerve transposition
Thompson et al[15] (2001)	Modified Jobe technique	83 UCL reconstructions; 65% professional
	Muscle-splitting approach	100% of athletes returned to sport
	Figure-of-eight graft	82% returned to same or higher level
	No ulnar nerve transposition	5% transient ulnar nerve irritability
Rohrbough et al[13] (2002)	Docking procedure modification	36 UCL reconstructions
	Routine arthroscopic assessment	33/36 (92%) returned to same or higher level
	Muscle-splitting approach	Average 3.3-year followup
	Two tendon ends of graft docked into single humeral tunnel
	Selective subcutaneous ulnar nerve transposition
Cain et al[5] (2002)	Andrews modification of original Jobe technique	342 UCL reconstructions with minimum 2-year followup
		96% baseball players; 45% professional, 45% collegiate, 10% high-school
		83% returned to same or higher level
		Average return: 11.4 months
Paletta and Wright[11] (2002)	Docking procedure	25 UCL reconstructions in professional or collegiate throwing athletes; 2-year minimum followup
	4-strand technique reconstruction	23/25 (92%) returned to same or higher level
		Average return: 12.5 months