Ulnar Collateral Ligament Repair With Suture Tape Augmentation

Abstract

Background:

The ulnar collateral ligament (UCL) is the primary static stabilizer of the medial elbow between 30° and 130° of elbow flexion. Athletes participating in overhead throwing sports, such as baseball, have the highest rate of UCL injury. High-grade injuries often require surgical intervention.

Indications:

Low-grade UCL injuries are typically treated nonoperatively; however, high-grade injuries can require surgical intervention for full healing and function to be achieved.

Technique Description:

A 5-cm incision is made from the medial epicondyle to the sublime tubercle to allow for dissection to the level of the flexor pronator fascia. Palpation is used to identify the sublime tubercle, the fascia is incised, and the flexor pronator musculature is split to reveal the underlying UCL. An ulnar anchor is placed, and the distal portion of the anterior bundle of the UCL is repaired with suture. Suture tapes were added around the suture, and a humeral anchor was placed. After all sutures were tied, the elbow was taken through the full range of motion to confirm that an isometric construct was successfully created.

Results:

This patient achieved a full, pain-free range of motion and a rapid return to sports (RTS) postoperatively. Current data suggest that UCL repair with suture tape augmentation may be advantageous over UCL reconstruction, as it demonstrates higher RTS rates.

Discussion/Conclusion:

UCL repair with suture tape augmentation is a viable alternative to UCL reconstruction in younger patients with good ligament quality who have sustained a UCL avulsion. A fast RTS and favorable postoperative outcomes can be achieved after this procedure, enabling motivated athletes to return to their sport. In older patients with UCL injuries, UCL reconstruction or hybrid UCL reconstruction with suture tape augmentation should be considered as a treatment option.

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

This video demonstrates the senior author's indications and technique for an ulnar collateral ligament (UCL) repair with suture tape augmentation.

Background

The UCL, which is composed of 3 bundles—anterior, posterior, and transverse—is the primary static stabilizer of the medial elbow between 30° and 130° of elbow flexion.^4-6,12 Athletes participating in overhead throwing sports such as baseball or javelin have the highest rates of UCL injuries. ¹² Particularly in baseball, UCL injuries are becoming increasingly common at both amateur and professional levels, and while most injuries are low-grade and can be treated nonsurgically, high-grade injuries often require surgical intervention for athletes who desire to return to sport (RTS). Historically, high-grade UCL injuries have been treated with reconstruction; however, recent advances in implant technology and surgical technique have led to a renewed interest in UCL repair, now augmented with high-tensile strength suture. In properly selected patients, suture-augmented repair of the UCL yields similar rates of RTS, with a significantly shorter time to RTS, compared with traditional UCL reconstruction. ³

Indications

We present a case of a right-hand dominant 14-year-old male baseball pitcher who presented with recurrent medial-sided right elbow pain that occurred exclusively in the layback position while pitching. He had a history of a right medial epicondyle avulsion fracture 1 year prior that healed uneventfully with rest. Additionally, the patient reported intermittent paresthesia in the fourth and fifth digits during and after pitching. The patient's physical examination was notable for full range of motion, tenderness to palpation at the sublime tubercle, a positive milking maneuver, and a positive moving valgus stress test. He had a negative Tinel sign at the elbow, and his ulnar nerve was stable in the cubital tunnel. Plain radiographs demonstrated no acute osseous abnormalities and a healed medial epicondyle in anatomic position. A magnetic resonance image showed a complete proximal rupture of the anterior band of the UCL. Given that the remainder of the ligament appeared to be of good quality and the patient desired to return to pitching, he was indicated for a UCL repair with suture tape augmentation.

Technique Description

Our preference is to perform this on the preoperative gurney with a hand table attachment. The entire right upper extremity is prepped and draped to allow for the application of a high sterile tourniquet.

A 5-cm incision was made from the medial epicondyle to the sublime tubercle. After sharply dissecting through the skin and dermis, fine-tipped scissors were used to advance the dissection to the level of the flexor pronator fascia. The medial antebrachial cutaneous nerve was identified in its typical location, adherent to the fascia and running obliquely through the surgical field roughly 2 to 3 cm distal to the medial epicondyle, and mobilized to allow for the case to proceed safely without injuring the nerve.

With the flexor pronator fascia exposed, digital palpation was used to identify the sublime tubercle. A scalpel was used to incise the fascia. Two Freer elevators were then used to gently split the underlying flexor pronator musculature along its fibers, exposing the UCL. Once the UCL is identified, a scalpel can be used to dissect and feather off the overlying muscle carefully.

The center of the sublime tubercle was then identified and marked with a marking pen. The UCL was then split longitudinally from its origin to its insertion to expose the joint line. A ruler was then used to identify the location of the ulnar anchor, which was placed 7 mm distal to the ulnohumeral joint line, aiming slightly distal posterior to avoid iatrogenically penetrating the articular surface.

With the ulnar anchor placed, the islet suture, which is 0 FiberWire (Arthrex), was used to repair the distal portion of the anterior bundle of the UCL. In the midportion of the UCL, a 2-0 FiberWire was placed in a figure-of-8 fashion. Finally, an additional 0 FiberWire repair stitch was placed in the proximal segment of the UCL.

A .045 k-wire was placed in the humeral origin of the isometric portion of the anterior bundle of the UCL, which originates at the junction of the lateral one-third and medial two-thirds of the medial epicondyle. With the wire in place, the suture tapes were used to assess the isometry of the proposed humeral anchor location by wrapping them around the wire and ranging the elbow from full extension to 100° of flexion. After confirming that the proposed humeral anchor is in an isometric position, the wire was overreamed with a 2.8-mm drill and tapped to accept the humeral anchor. Then, a 0 FiberWire was placed in the proximal end of the UCL in a figure-of-8 fashion. Next, the distal and mid-UCL repair stitches were tied. Finally, both limbs of the proximal repair stitch, as well as both limbs of the SutureTape, were loaded into the humeral anchor. A Freer elevator was placed under the tape to avoid overtensioning, and the anchor was subsequently inserted. Once again, the elbow was taken through the full range of motion to confirm an isometric construct that would not overconstrain the joint.

Lastly, the incision is closed beginning with the flexor-pronator mass fascia, followed by standard interrupted dermal and running subcuticular absorbable sutures. A sterile dressing was applied, and the patient was placed in a hinged elbow brace locked at 90º of flexion.

Results

For the first week postoperatively, patients are to remain in a brace locked at 90° of flexion. After this, patients may begin range of motion exercises to add 20° of range per week, aiming to achieve full, painless range of motion by 6 weeks postoperatively. Suture removal occurs at 10 to 14 days postoperatively, and physical therapy is initiated at 2 weeks. Starting at 6 weeks after surgery, patients may begin light strengthening exercises. At 12 weeks after surgery, a program aimed at achieving full strength can be initiated. For overhead athletes, a throwing program typically starts between 12 and 16 weeks postoperatively. For pitchers, the mound portion of the throwing program typically begins at the 6-month time point, and most can return to live in-game pitching at 8 months postoperatively.

Relevant complications of the procedure include bleeding, infection, neurovascular injury, heterotopic ossification, and recurrent instability. ¹⁰ There is an overall complication rate of 8.7% with ulnar nerve neuropraxia occurring at a rate of 6%, making it the most common complication. ¹⁰ Retear is one of the rarer complications occurring at a rate ¹⁰ of 0.02%. Return to the operating room for ulnar nerve transposition, excision of heterotopic ossification, or repair of a retorn UCL has been reported at a mean rate ¹⁰ of 5.3%.

UCL repair outcomes with suture tape augmentation have been of great interest to elbow surgeons, with multiple studies reviewing athlete return to sport (RTS) data and patient-reported outcomes (PROs).^1-3,7-11 In their systematic review, Spears et al ¹⁰ reported that among the 4 studies on RTS after UCL repair with suture tape augmentation and a total of 201 elbows, 93% of athletes were able to RTS at the same level or higher after mean times of 3.1 and 7.4 months.

Rothermich et al ⁹ studied American Shoulder and Elbow Surgeons (ASES) scores after UCL repair with suture tape augmentation, and found a mean postoperative score of 94.4 among 28 patients. Spears et al ¹⁰ reported on postoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) scores with a range of 86.2 to 95.3. KJOC scores are similar among high school and collegiate athletes, and improve significantly between preoperative values and 6 months postoperatively, and then continue to improve slightly over the following 18 months (an increase of 5.3% between 6 and 12 months; an increase of 5.7% between 12 and 24 months).^8,10,11

Discussion/Conclusion

Historically, UCL repair was considered unsuccessful after Conway et al ¹ compared isolated UCL repair with UCL reconstruction in 1992. They found that the repair technique had a lower RTS rate compared with reconstruction, with professional athletes doing exceedingly poorly after repair alone, with an RTS of 29%. Since then, thanks to advances in anchor and suture technology, UCL repair with suture tape augmentation has made significant strides, with current data demonstrating high RTS rates and faster time to RTS in patients who undergo UCL repair with suture tape augmentation compared with reconstruction. ² Additionally, data have shown favorable outcomes with no difference between UCL repair with suture tape augmentation and reconstruction among multiple PROs, including KJOC, ASES form (ASES-E), Patient-Rated Ulnar Nerve Evaluation, and Andrews-Carson scores. ²

The senior author's surgical approach to treating UCL tears is presented here. While the reconstruction of the UCL using a tissue graft or a hybrid method of a tissue graft along with suture tape is a valid technique, the senior author prefers UCL repair with suture tape augmentation for young patients with good ligament quality who have an avulsion of the proximal or distal end of the UCL. By using this technique, favorable PROs and a faster RTS can be achieved in athletes who are highly motivated to return to their prior level of play. For more complex and extensive tears of the UCL in older patients or in those with poor tissue quality, a more aggressive form of management may be more suitable, such as UCL reconstruction or a hybrid UCL reconstruction with suture tape augmentation.