Ulnar Collateral Ligament Reconstruction with Hamstring Autograft

Abstract

Background:

Ulnar collateral ligament (UCL) reconstructions have become increasingly common, particularly in youth overhead throwing athletes. These injuries are most commonly due to overuse and repetitive trauma on the inner elbow. Throwers with a deficient UCL often report decreased pitching speeds in addition to elbow pain and instability.

Indication:

The indications for this procedure include symptomatic valgus elbow instability during overhead throwing motions and a verified rupture of the UCL on advanced imaging.

Technique Description:

The ipsilateral gracilis tendon is harvested and prepared as an autograft. A 5-cm incision is then made centered over the medial epicondyle. The ulnar nerve is identified and neurolysis is performed both proximally and distally. The fascia overlying the flexor carpi ulnaris is incised, and the two heads of the muscle are split. From this base, the sublime tubercle is identified, and the UCL is opened longitudinally in line with its fibers. A standard guide is used to drill holes in the posterior and anterior aspects of the sublime tubercle. These holes are then connected using a curved curette, and a suture is passed along the tunnels for later graft passage. A 15-mm blind-end tunnel is drilled two-thirds from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with K-wires to pass sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is then passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is then undertaken so that both ends are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the two limbs of the graft are sutured together to appropriately tension the graft.

Results:

In our experience, 94% of athletes return to previous levels of play and experience high patient-reported outcome scores.

Discussion/Conclusion:

Advancements in UCL reconstruction techniques and our understanding of elbow anatomy should prompt surgeons to continue considering this treatment for patients with significant throwing pain and a strong desire to return to high levels of throwing.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

I’m Dr. Nikhil Verma, and I’d like to share with you our technique for ulnar collateral ligament (UCL) reconstruction from Rush University Medical Center in Chicago, Illinois.

We know that medial elbow pain is exceedingly common in the overhead throwing athlete and the most common cause of medial elbow pain is insufficiency related to the UCL. This most commonly occurs based on overuse or repetitive microtrauma, but in some situations can occur based on a single acute event. Associated conditions are common and include irritation of the ulnar nerve, osteophytes in the olecranon, posteromedial impingement, as well as development of arthritis in the elbow.

We all should be familiar with the anatomy of the medial side of the elbow and particularly the UCL which has 3 components: the anterior bundle, the posterior bundle, and the transverse ligament.

The main restraint to valgus force in the elbow for the throwing athlete is the anterior bundle, which is active between 30° and 120° of flexion. The anterior bundle has both an anterior and posterior band. They originate from the anteroinferior surface of the medial epicondyle about two-thirds away from the epicondyle tip to the epicondyle base. They have a broad insertional footprint at the sublime tubercle which terminates in the osseous ridge of the ulna.

There has been a significant increase in UCL reconstructions; in fact, at this point in time more than 1 in 3 professional baseball pitchers will undergo a UCL reconstruction at some point in their career. The incidence of UCL injuries in our amateur athletes, particularly at the high school and collegiate levels, continues to rise at an alarming rate.

An example of a case from our practice is an 18-year-old, right-hand dominant, high school pitcher. He had 2 weeks prior to presentation medial elbow soreness followed by a pop and therefore removed himself from a game. He did report numbness and tingling in the ulnar distribution, and he had no prior history of an elbow condition. His examination demonstrated tenderness over the ulnar collateral ligament. He had a painful, positive moving valgus stress test and milking maneuver. His range of motion was generally maintained. He had a negative Tinel sign and normal shoulder strength and range of motion.

His diagnostic imaging began with plain radiographs, including an AP lateral and oblique view. You can see that the appearance of the sublime tubercle is normal. The radiocapitellar and ulnohumeral joint spaces are normal, and there is no evidence of either osteophyte formation, ossification, or calcification within the substance of the ligament. A magnetic resonance imaging (MRI) scan was therefore ordered, and it demonstrates a distal avulsion of the ulnar collateral ligament with surrounding edema in the flexor pronator.

Our technique for reconstruction includes ulnar nerve transposition. We generally offer graft choices including palmaris longus, hamstring autograft, or hamstring allograft. In this case, a hamstring autograft was selected.

The patient is placed into a supine position with the right elbow on an elbow board and a sterile tourniquet is used to control bleeding during the procedure itself. The hamstring, particularly the gracilis, is harvested from the ipsilateral lower extremity and that wound is closed before proceeding to the elbow procedure. Once the graft is harvested, a #1 FiberWire is incorporated into the graft at the proximal end of the tendon. The elbow reconstruction then begins centered on the medial epicondyle, extending proximally for about 5 cm just posterior to the intermuscular septum and distally over the sublime tubercle for a distance of 5 to 6 cm.

We begin our dissection by identifying the ulnar nerve. The ulnar nerve is freed in both the proximal and distal dissection using sharp dissection. A penrose drain is placed along the nerve to identify and free up the nerve for mobilization. We extend our split distally through the 2 heads of the flexor carpi ulnaris.

At this point, we prefer to come through the base of the flexor carpi ulnaris to identify the sublime tubercle. The sublime tubercle is identified, and the ulnar collateral ligament is opened inline. We palpate the sublime tubercle and then use a standard guide to drill holes in both the posterior and anterior aspects of the sublime tubercle, separating the holes by about 1 cm. These holes are then connected using a curved curette and a suture is passed along the tunnels for later graft passage.

Here you can see we’ve elevated the anterior flexor pronator mass to allow exposure of the humeral epicondyle. We come to the base of the humeral epicondyle, basically two-thirds from the tip to the base, and drill a 15-mm blind end tunnel. This tunnel is about 4.5-5 mm dependent on the size of your graft. Then 2 smaller tunnels are drilled with K-wires to pass sutures through the posterior aspect of the epicondyle which will later be used to dock the graft. There are systems that are available to help with suture passage and graft passage and in this system, a guide system is used to make sure that these smaller tunnels approximate the larger tunnel so that the graft can be docked appropriately.

Next, the joint is irrigated and we close the native UCL in a layered fashion. We can leave one of these sutures free, either proximally or distally, that can be incorporated into the tunnel for primary repair of the native ligament.

At this point, the first step is to pass the graft through the sublime tubercle tunnels, and we dock one end of the graft into the epicondylar tunnel. We then tension the graft and make sure to mark the length of the graft so that we can place our second passing suture within the graft over a distance of about 15 mm. Here you can see those marks being made. Next, we take a loop suture and secure the graft on this end before transecting the graft at the appropriate length.

At this point, a docking procedure is undertaken so that both ends of the graft are docked within the humeral tunnel. They can be tensioned, and the graft can be visualized as the elbow is taken through a range of motion to confirm that the graft has appropriate tension.

Here we demonstrate the graft being docked into position and each loom of the graft is sequentially tensioned to ensure that there is adequate graft material within the tunnel and that the graft has appropriate tension. Once we are happy with the tension and position, we tie the stay sutures over a bone bridge making sure to keep the knot in a posterior position to avoid any irritation of the nerve. Then, the 2 limbs of the graft are sutured together to appropriately tension the graft.

Next, we move the ulnar nerve into an anteriorly transposed position. We take care to make sure that there is no tension on the nerve itself. Two subcutaneous stitches are used through the flexor-pronator mass into the subcutaneous tissue of the anterior skin flap to maintain the ulnar nerve into position. Great care is taken here to be sure that the ulnar nerve is not entrapped and that there is free mobility of the ulnar nerve as it passes through the subcutaneous tunnel anteriorly to avoid any subsequent ulnar nerve scarring or tension. At this point, we can palpate the ulnar nerve to be sure that it has a smooth course with no abrupt impingement of the nerve as it passes anteriorly to the epicondyle and the elbow is ranged to be sure that the nerve has adequate excursion.

For our postoperative protocol, we place the patient into a postoperative splint immediately after surgery and they remain in the splint for 1 week. At that point, they are seen in follow-up and placed into a hinged elbow brace locked between 15° of terminal extension and full flexion and allowed to range within this arc up until 4 weeks. They initiate grip strength and physical therapy begins immediately after the initial postoperative splint is removed. By week 4, the brace is discontinued and the goal is to reestablish full range of motion symmetric to the opposite elbow by about 6 weeks after surgery. We avoid any valgus stress on the elbow until a minimum of 8 to 12 weeks postoperatively at which time strength training is initiated. Generally, we begin an interval throwing program somewhere between 4 and 5 months postoperatively assuring that the patient has full range of motion, no pain in the elbow, and adequate core strength and upper extremity strength more proximal. A pitching mound program generally begins after completion of long toss with a goal of return to competitive throwing by 9 to 12 months after surgery.

Outcomes following UCL reconstruction have been overall very reproducible within the literature with many studies reporting greater than 90% success of return to sport and an average of 14 months after surgery. ¹ Our experience has been published in 2016 indicating a 94% return to sport at the preoperative injury level with a mean KJOC score of 90.4. ²

Thank you very much for your attention.