Revision Ulnar Collateral Ligament Reconstruction

Jeremy R. Bruce, MD; Neal S. ElAttrache, MD; James R. Andrews, MD


J Am Acad Orthop Surg. 2018;26(11):377-385. 

In This Article

Imaging Studies

Standard radiographic elbow series consisting of AP, lateral, oblique, valgus stress, and reverse axial (ie, cubital tunnel) views should be obtained (Figure 1). Calcifications are a common finding along the graft after UCL reconstruction.[12] Tunnel widening should also be assessed for revision planning (Figure 2). In addition, medial epicondyle fractures are a documented complication of UCL reconstructions and are likely caused by the stress riser created from drill tunnels (Figure 3).

Figure 1.

Reverse axial radiograph (ie, cubital tunnel view) of the elbow demonstrating a posteromedial olecranon osteophyte in a patient who had previously undergone ulnar collateral ligament reconstruction.

Figure 2.

AP radiograph of the elbow demonstrating tunnel widening at the medial epicondyle in a patient who had previously undergone ulnar collateral ligament reconstruction.

Figure 3.

A, AP radiograph of an elbow demonstrating a displaced medial epicondyle fracture after an ulnar collateral ligament reconstruction. B, AP fluoroscopic image of the elbow demonstrating fixation of a medial epicondyle fracture with a compression screw and washer.

Radiography can be used to compare medial joint openings with valgus stress. For this comparison, stress radiographs should be obtained of both elbows. However, recent studies have shown that pitchers with symptomatic UCL injuries have a valgus opening similar to that of asymptomatic pitchers, calling into question the relevance of such stress radiographs.[13–15]

MRI can help define the soft-tissue anatomy; however, results are often difficult to interpret in the setting of previous surgical reconstruction (Figure 4). Magnetic resonance arthrography can further enhance pathology and visualization of partial tears. When combined with ultrasonography (US), magnetic resonance arthrography can further increase the sensitivity and accuracy of diagnosing UCL tears.[16]

Figure 4.

Coronal T2-weighted MRI demonstrating a failed graft from a previous ulnar collateral ligament reconstruction.

When artifacts on MRI distort images, US can be a valuable tool, especially in the setting of previous UCL reconstruction. Using stress US in a cadaver study, Ciccotti et al[17] demonstrated that release of the anterior band of the anterior bundle resulted in a mean difference of 2.0 mm in joint opening, whereas release of the posterior band resulted in a mean difference of 1.4 mm. In another study of stress US in asymptomatic professional baseball pitchers, Ciccotti et al[18] demonstrated that the dominant elbow UCL was thicker than that of the nondominant elbow, was more likely to have calcifications, and had increased laxity with valgus stress.