Ulnar collateral ligament repair

OVERVIEW

Chapter synopsis

Traditional operative treatment of ulnar collateral ligament (UCL) injury in the throwing athlete consists of reconstruction with autogenous graft. However, some athletes can have a UCL injury isolated to either the humeral or ulnar insertion without significant attritional, degenerative changes. Such patients may be candidates for a direct, primary ligament repair, which allows earlier return to competition than a reconstruction with similar high rates of success.

Important points

For repair, patients must have injury isolated to either the humeral or the ulnar insertion without significant ligament damage or deficiency.
The surgeon and patient should both be alert to the possibility of a reconstruction based on intraoperative findings.
The surgeon should assess the patient for concurrent pathology, such as ulnar nerve irritation and posteromedial impingement.

Clinical/surgical pearls

The native UCL should be thoroughly inspected at the time of surgery to evaluate for ligament quality, potential tissue loss, and tear location to ensure appropriateness of repair over reconstruction.
Appropriate patient selection is necessary for success.
UCL repair can successfully return throwing athletes back to sport after a significantly shortened rehabilitation time compared with reconstruction.

Clinical/surgical pitfalls

To avoid compression of the ulnar nerve when the flexor muscle tendon split is performed, do not use a retractor against the bone inferiorly.
When sutures are passed through the ligament proper posteriorly, care should be taken to avoid the ulnar nerve.

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 tremendous valgus stress on the elbow that is resisted by the medial structures. The anterior bundle of the ulnar collateral ligament (UCL) has been shown to be the primary restraint to valgus stress about the elbow. 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 manifest as disabling elbow pain with the inability to compete effectively. Various techniques of UCL reconstruction have been reported with high rates of success in returning the athlete to competition; however, an increased incidence of UCL injuries in younger patients has led to consideration of primary repair as a surgical option. Many young athletes may have injury that is isolated to either the humeral or the ulnar insertion and thus is amenable to direct repair, perhaps allowing earlier return to sport. Recent reports have detailed high rates of success in early follow-up. Constants in operative management include an accurate diagnosis, careful patient selection, anatomic repair of the UCL insertion, 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 most commonly report a 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. Less commonly, patients report a history of a fall on an outstretched hand or direct trauma to the elbow followed by medial elbow pain and swelling. Symptoms of ulnar nerve irritability, such as paresthesia in the little and ring fingers, can 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 present and 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”
Moving valgus stress test

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. The possible presence of concurrent posteromedial impingement in the thrower’s elbow can be evaluated with the valgus extension overload test.

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