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Address correspondence to Anthony J. Scillia, M.D., St. Joseph's University Medical Center, Hackensack Meridian School of Medicine at Seton Hall University, Department of Orthopaedic Surgery, 703 Main St., Paterson, NJ 07503. U.S.A.
Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New JerseySeton Hall University, South Orange, New JerseyHackensack Meridian School of Medicine, Nutley, New Jersey
Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.
Technique Video
See video under supplementary data.
Ulnar collateral ligament (UCL) injuries of the elbow are most often a result of intense valgus forces placed on the elbow and frequently occur in young overhead athletes.
The first reconstruction technique, performed by Dr. Frank Jobe, was made famous by notable Major League Baseball player Tommy John, who underwent the original “Tommy John” procedure to reconstruct his UCL in 1974. The UCL reconstruction allowed for a more successful career after surgery.
Since the inception of the Jobe technique, there have been several modifications that have resulted in improved clinical outcomes and return to play rates reported as high as 80% to 95%. In 2000 Dr. James R. Andrews published his modified Jobe technique, which was performed without detaching the flexor pronator mass and using a subcutaneous ulnar nerve transposition.
reported quicker return to play with a collagen-dipped FiberTape internal brace construct, but it was only applicable to a specific subset of UCL injuries occurring in young patients with an avulsion and good tissue quality.
UCL injuries are first treated conservatively with rest and physical therapy, but when first-line treatments fail, surgical intervention may be recommended, particularly for athletes desiring to return to sport. The authors present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.
Surgical Technique
Indications
Patients who receive a diagnosis of UCL tear typically present with elbow pain, swelling, and valgus instability, which limits their participation in sports, particularly gymnastics, and overhead throwing athletes, such as baseball players. Patients in whom first-line treatments of rest and physical therapy fail and who are functionally limited by the laxity and pain in the elbow are indicated for surgical intervention.
Patient Positioning
The patient is placed in the supine position, a tourniquet is applied (Fig 1A ), and the operative extremity is abducted to 90°, externally rotated, and supinated on an arm board, with a half stack of towels under the elbow and a full stack under the hand (Fig 1B). The standard medial approach is made with care to avoid neurovascular structures (Video 1).
Fig 1(A) The patient is placed in the supine position, and a tourniquet is applied to the right upper extremity. The extremity may be hung for appropriate sterile preparation and draping. The arm is abducted to 90° on the arm board, supinated, and externally rotated. (B) The medial elbow is marked with identification of the medial epicondyle (yellow arrow) for the standard medial approach, with caution taken to avoid neurovascular structures such as the medial antebrachial cutaneous and ulnar nerves (red arrows).
The medial antebrachial cutaneous (MABC) nerve is identified, mobilized, and retracted during the entirety of the case (Fig 2A ). A flexor pronator muscle split is performed, and, if needed, tissue is debrided and irrigated. The UCL is split to identify distal and proximal attachments anatomically and will later be repaired (Fig 2B). The anatomic distal attachment on the sublime tubercle is identified (Fig 2C). The joint surface should also be visualized at this time.
Fig 2(A) The right medial elbow dissection is viewed during blunt dissection; the medial antebrachial cutaneous and ulnar nerves (green arrow) are identified and retracted for the entirety of the case. A fascial split is then made in the flexor pronator mass. (B) The ulnar collateral ligament (UCL) is split (black arrows) to identify the distal attachment at the (C) sublime tubercle (star) and joint surface.
The sublime tubercle is drilled with care to angle away from neurovascular structures and the joint line using a 3.5 mm drill bit (Fig 3A ). The tunnel is subsequently widened with a 4.0 mm drill bit, which is marked with a Steri Strip as a depth gauge because there is no drill guide (Fig 3B). The tunnel is irrigated, suctioned, and then tapped (Fig 3C). Subsequently the Knotless FiberTak (Arthrex, Naples, FL) anchor is drilled to the base of the tunnel (Fig 3D). The distance between the proximal and distal attachments of the UCL is measured to plan for appropriate graft preparation (Fig 3E).
Fig 3(A) The dissection of the right medial elbow is viewed. The insertion of the ulnar collateral ligament (UCL) at the sublime tubercle is drilled with a 3.5 mm drill bit, angling away from the neurovascular structures and joint line. (B) It is subsequently widened by a 4.0 mm drill bit with the depth marked by a steristrip (yellow arrow). (C) The tunnel is irrigated, suctioned and tapped. (D) A Knotless FiberTak is then drilled. (E) The distance between attachments of the UCL is measured to plan for graft preparation.
At this time the semitendinosus allograft is prepared on the backtable. A large semitendinous or gracillis graft is reduced in width to 4 mm corresponding to the tunnel diameter if necessary. It is marked with a sterile marking pen to the previously measured length between proximal and distal attachements of the native UCL. An additional 1 cm is added to each end of the graft to account for the depth of the tunnel. The graft is secured with alice clamps and the 1 cm ends are then whipstiched with no. 2 Fiberwire (Arthrex) tensioning after each pass and taking care not to suture in the same plane so as not to weaken the integrity of the graft (Fig 4A ). A no. 2 Fiberwire locking suture is then placed between the distalmost sutures, which will later be used to thread a tail of the whipstitch before final fixation to prevent pullout (Fig 4B).
Fig 4Prepared on the back table, the semitendinosus or gracilis graft is marked to the distance between the proximal and distal attachments of the ulnar collateral ligament (UCL), and an additional 1 cm is added to each end. (A) The graft is secured with Alice clamps and then whipstiched with no. 2 Fiberwire. (B) A locking suture is placed to prevent pullout.
The tails of the whipstich are then passed through a loop created by the Knotless FiberTak suture, which is used to assist in shuttling the graft into the base of the tunnel at the sublime tubercle (Fig 5A ). One limb of the whipstitch is shuttled back through the graft using the earlier placed locking suture (which is removed in the process), and the 2 limbs of the whipstich are tied with an arthroscopic knot pusher and cut to appropriate length (Fig 5B) for backup fixation. A 3.5 mm SwiveLock (Arthrex) loaded with collagen-dipped FiberTape is then placed for interference fixation (Fig 5C). The native ligament is repaired side to side with no. 2 FiberWire but not tied at this time because it would prevent access to the proximal attachment (Fig 5D).
Fig 5Surgical images of the previously drilled tunnel at the sublime tubercle of the right medial elbow are viewed. (A) The whipstitch tails are passed through the loop of the suture from the knotless FiberTak and reduced into the base of the tunnel at the sublime tubercle. One limb of the whipstich is shuttled back through the graft and (B) tied with an arthroscopic knot pusher for backup fixation. (C) A 3.5 mm SwiveLock with FiberTape is then placed for interference fixation. (D) The graft is covered with a moist lap, and native ligament is surtured side to side with no. 2 FiberWire but not tied.
A similar preparation of the medial epicondyle is performed with a 3.5 mm drill and 4.0 mm drill to widen the tunnel. Great care is taken to avoid penetration through the far cortex, angling up the humeral shaft and away from the ulnar nerve. The Knotless FiberTak is drilled and placed in the base of the tunnel. The tunnel is irrigated, suctioned and tapped to the size of the anchor. The graft is measured once again and excess is removed (Fig 6A ). The proximal end of the graft is then reduced into the tunnel (Fig 6B) again using the loop created from the FiberTak suture. The tails of the whipstich are passed through the graft with assistance from the previously placed locking suture, again used to pass one limb of the whipstich through the graft. Both limbs of the whipstick are tied with an arthroscopic knot pusher and cut to appropriate length. The previously placed FiberWire sutures through the native ligament are tied and cut to the appropriate length. The FiberTape is tensionsioned with great care to avoid overtensioning. A hemostat may be placed under the tensioned FiberTape to prevent overtensioning (Fig 6C). The FiberTape is then marked with a sterile marking pen to the first laser line of the SwiveLock inserter (Fig 6D), and the tip of the inserter is then backed out to the mark (Fig 6E). Interference fixation is then achieved with the 3.5 mm SwiveLock.
Fig 6Surgical images of the medial right elbow are viewed. (A) A similar preparation is performed on the medial epicondyle with great care to avoid penetration through the far cortex, angling up the humerus and away from the ulnar nerve. (B) The graft is reduced in the proximal tunnel. (C) After tensioning the FiberTape, with great care taken to avoid overtensioning, (D) the FiberTape is marked with a sterile marking pen acording to the laser line depth marker on the 3.5 mm SwiveLock (red arrows) and (E) backed out (white arrow) to the mark that corresponds to the depth of the tunnel before insertion of the SwiveLock.
The elbow is checked throughout range of motion (flexion, extension, supination, and pronation) with attention to stability and tension without limitation in range of motion. The FiberTape and the FiberTak sutures are used to repair the flexor pronator mass and tails cut to appropriate length. The wound is irrigated, suctioned and hemostasis achieved with electrocautery. The tourniquet is released. The fascia is closed with 3-0 Vicryl (Fig 7A ). The wound is closed with 4-0 Monocryl (Fig 7B). Sterile dressings and a hinged teloscoping range of motion brace are applied. A summary of technique pearls and pitfalls is provided in Table 1.
Fig 7Surgical images of the closure of the right medial elbow incision are viewed. (A) Repair of the fascia is achieved with 3-0 Vicryl, and the (B) skin is closed with 4-0 Monocryl.
Table 1Technical Pearls and Pitfalls of Medial Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace
Utilization of an assist to ensure proper positioning of the arm which will aid in proper identification of landmarks prior to incision and avoidance of neurovascular structures.
The medial antebrachial cutaneous and ulnar nerves are identified and protected throughout the case.
An adequately sized incision is necessary for proper visualization of landmarks, proper retraction to protect neurovascular structures and access to good tunnel placement.
Care should be taken not to drill “in-out-in” into the ulnar nerve when drilling the medial epicondyle.
Subsequent irrigation and suctioning of the tunnel is necessary for removal of bone debris. Failure to remove debris may result in the inability to fully reduce the graft into the tunnel or heterotrophic ossification.
When preparing the semitendinous or gracilis graft, reduce the width of the graft to correspond to the diameter of the tunnel so that it fits securely and reduces fully.
The placement of the side to side suture repair of the native ligament is performed after reduction of the graft into the first tunnel but is not tied so that adequate exposure of the second tunnel site is maintained. The side to side repair may be tied after the graft is in place and fully fixated.
To prevent overtensioning of the internal brace and subsequent loss of motion with decreased range of motion, a hemostat should be placed under the FiberTape during tensioning and final fixation.
During closure, ensure good soft tissue coverage of the graft and sutures.
The patient is placed in a teloscoping range of motion brace at the completion of surgery, and it is limited to 30° to 110° passive range of motion (ROM) during the first week after surgery. The goal of the next 4 to 6 weeks is to restore full ROM. After full ROM is achieved, patients progress to a strength training program at >6 weeks after surgery. Progression to more-advanced strength training is based on the achievement of nonpainful, full active ROM and typically occurs at >9 weeks. If ROM and full strength have been achieved, a thrower may begin a throwing program at >10 weeks. A gradual return to play is based on position and skill level and usually occurs at 4 to 9 months.
Discussion
While UCL injuries were formerly career ending for baseball players, the evolution of the Jobe technique has brought about improved outcomes and return to play rates. UCL reconstruction became the standard for optimizing return to play in overhead athletes, particularly baseball pitchers.
The lengthy recovery associated with reconstruction is problematic for many athletes, and, in an effort to expedite recovery, repair has also been popularized by Dugas et al.
As a result, there has been an increase in the number of UCL repairs performed in recent years.
Still a topic of debate is the rate and timeframe at which these athletes return to high levels of play. Return to play usually occurs after a lengthy recovery and rehabilitation period, although these have improved over the evolution of techniques. Dugas et al.
discuss the advantages of UCL repair with internal brace, concluding that it is an option for a subset of young athletes who desire a speedy return to play and who have an avulsion injury with adequate tissue quality. Quicker return to play rates have been reported with the use of internal brace and repair versus reconstruction.
The literature is sparse when it comes to direct comparisons of surgical technique or clinical outcomes; however, some suggested advantages and disadvantages are proposed. The graft choice and technique for reconstruction appear to be widely varied according to a systematic review by Erickson et al.
Possible advantages of the proposed technique include treatment of the flexor pronator mass in which splitting, as compared to transection, has been shown to have improved return-to-sport rates.
The combination of allograft reconstruction with internal brace marries the clinical advantages of high rates of return to play with the possibility of a shortened timeline of recovery because the internal brace may provide protection from mechanical forces allowing the allograft time to heal.
The treatment of the ulnar nerve continues to be discussed, and one possible disadvantage is that no ulnar nerve transposition was performed.
The technique presented restores the anterior bundle of the UCL, the primary valgus stabilizer of the elbow, by using a collagen-coated internal brace to provide instant stability, an allograft reconstruction for tissue incorporation and longevity, and bone-sparing single tunnels. Further investigation is warranted into the return to play and time to return to play as compared to other techniques. We propose this technique as an additional tool to be used in the surgical intervention of UCL injuries.
Acknowledgments
The authors thank Jon Gribben and Jarrod Mundy from Arthrex.
The technique presented demonstrates an elbow ulnar collateral ligament allograft reconstruction with internal brace. The patient is positioned supine, with the right upper extremity abducted, externally rotated and supinated on an arm board. The standard medial approach with a muscle split to gain access to the sublime tubercle and medial epicondyle. Each are prepared in the same fashion including drilling, tapping and placement of a Knotless FiberTak. The allograft is reduced first into the distal tunnel and interference fixation achieved with collagen-dipped FiberTape loaded SwiveLock. The same preparation is made on the medial epicondyle. Range of motion is checked and the wound closed.
References
Lawton C.D.
Lamplot J.D.
Wright-Chisem J.I.
James E.W.
Camp C.L.
Dines J.S.
State of the union on ulnar collateral ligament reconstruction in 2020: Indications, techniques, and outcomes.
The authors report the following potential conflict of interest or source of funding: A.J.S. reports stock or stock options from Biomet, Conmed Linvatec, Johnson & Johnson, Pfizer, Smith & Nephew, Stryker; personal fees from Mitek and Isto Biologics; and board or committee membership for the American Orthopaedic Society for Sports Medicine and the New Jersey Orthopaedic Society. B.B.B. reports personal fees from Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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