Ulnar Collateral Ligament Reconstruction: Complications and Salvage

Treatment

The vast majority of ulnar nerve complications following UCL reconstruction can be treated symptomatically. However, in recalcitrant cases, more aggressive treatment may be pursued. If ulnar nerve symptoms persist for 3 months, it is the senior author's (JRA) preference to perform electrodiagnostic studies to evaluate nerve status. If severe neuropathy or significant motor symptoms are identified, neurolysis is performed through the same incision as that used for the reconstruction. Care must be taken not to injure the branches of the medial antebrachial cutaneous nerve because they are likely encased in fibrous scar tissue. The same must also be said for the ulnar nerve if a transposition was performed during the index procedure. Technically, it can be very difficult to differentiate from surrounding scar tissue ( Fig. 69.1 ).

Infection

Infection is a possible complication following any surgical procedure, and UCL reconstruction is no exception. Cain et al. reported a 4% rate of superficial infection at the graft harvest site. However, the authors reported no superficial or deep infections at the site of the UCL reconstruction. All these superficial infections resolved with oral antibiotics. Azar et al. reported superficial infections at the palmaris harvest site in 2 of 91 patients. They also reported a superficial infection at the site of the UCL reconstruction in 1 of 91 patients, and these also resolved with oral antibiotic treatment.

Although infection following UCL reconstruction is infrequent, it usually can be managed with oral antibiotic therapy when it does occur. In the rare event of a deep infection, irrigation and débridement are warranted; however, to date, there have been no reported cases of deep infection in the literature.

Fracture

Although rare, a postoperative fracture of the medial epicondyle or ulnar bone tunnel following UCL reconstruction can be devastating. Cain et al. reported medial epicondyle avulsion fractures in only 0.5% of patients undergoing UCL reconstruction using the American Sports Medicine Institute (ASMI) technique ( Fig. 69.2 ). Paletta et al. reported no fractures at 2-year follow-up in 25 elite overhead athletes undergoing reconstruction using the docking technique. Even more rare than medial epicondyle fracture is a fracture of the bone bridge between the ulnar tunnel drill sites ( Fig. 69.3 ).

Treatment of epicondylar fracture following reconstruction is open reduction and internal fixation if the fragment size allows this to be done. The epicondyle is approached through the same incision as that used for the reconstruction. Care must be taken to identify, mobilize, and protect the ulnar nerve throughout the procedure. The fracture site is prepared by removing any intervening hematoma and fibrous tissue so that a precise reduction can be obtained. The reduction should be held with clamps or temporary Kirschner wires. Definitive fixation is obtained by using a 4.5-mm, partially threaded cannulated stainless steel screw placed across the fracture into the medial column of the distal humerus. A washer can be used to help distribute forces on the medial epicondyle fracture fragment ( Fig. 69.4 ).

Conservative management can be attempted for fractures of the ulnar bone tunnel. Complete rest is required. If the fracture fails to heal, revision UCL reconstruction with placement of the ulnar bone tunnel more distally should be considered. Alternatively, fixation can be achieved in the opposite cortex of the ulna ( Fig. 69.5 ). Open reduction and internal fixation of the small piece of bone can be exceedingly difficult and should usually not be attempted.

Graft Failure

The number of UCL reconstructions being performed nationwide has continued to increase exponentially. Petty et al. noted an increase in UCL reconstructions from 85 in 1988 to 1994 to 609 from 1995 to 2003. This trend was also seen by Andrews et al., who noted an increase in the number of reconstructions done from nearly 500 in 1999 to 2002 to almost 800 over the next 3-year period, 2003 to 2006.

Studies show that an average of 15 to 20 Major League Baseball (MLB) pitchers undergo UCL reconstruction each year. In 2012, that number increased to 33 MLB pitchers requiring UCL reconstruction. A 2012 to 2013 survey found that 25% of major league and 15% of minor league pitchers have undergone UCL reconstruction at some point in their careers.

With such large numbers of UCL reconstructions being performed, one would assume a similar exponential increase in revisions being performed. However, in the largest series of UCL reconstructions to date, only 1% of over 700 athletes required a revision UCL reconstruction. The retear rate for surgically reconstructed UCLs in another large series was reported as low as 2% (9 of 449). In contrast, in 2015, a study of 271 professional pitchers found that 40 (15%) had undergone revision surgery. This increase in UCL revisions may have been caused by rushing the pitcher's rehabilitation and returning to competition too quickly. Although the rates have been increasing for revision surgeries, this is still a rare procedure, making proper diagnosis, surgical technique, and rehabilitation of utmost importance.