Repair of the Ulnar Collateral Ligament: A Review of Current Trends and Outcomes

James S. MacKenzie, MD; Daryl C. Osbahr, MD

Disclosures

Curr Orthop Pract. 2022;33(4):315-319. 

In This Article

Abstract and Introduction

Abstract

Diagnosis and surgical treatment of elbow ulnar collateral ligament (UCL) injury is becoming more common. A thorough understanding of nonsurgical and surgical options for this injury is required for successful treatment. Gold standard treatment remains ligamentous reconstruction with autograft in the elite throwing athlete. However, advances in surgical technique, technology, and a better understanding of the pathoanatomy of the injury have renewed interest in primary repair of the UCL. Recent literature has shown encouraging results with primary repair and with augmented primary repair, especially over the past 5 yr. This review describes the recent trends and outcomes of UCL repair so that surgeons can have a better understanding of surgical options.

Introduction

Since the initial description in 1986 by Dr. Frank Jobe,[1] surgical treatment of the ulnar collateral ligament (UCL) has evolved in terms of diagnosis, surgical approach, and the treatment itself. Although Jobe first described surgical reconstruction of the UCL, Waris et al.[2] published the initial clinical description of UCL injury in 1946 examining elbow injuries in javelin throwers.[2] Depending on the severity of the injury and level of athletic demand, initial treatment for the majority of patients includes rest and proper rehabilitation.[3–7] Nonoperative management often proves effective in patients with sprains, partial tears, or low athletic demands.[3,6–9] Tear location is another important factor to consider when considering nonoperative management. Proximal tears or avulsions in general offer a better prognosis with nonoperative treatment.[10] When nonoperative management fails, reconstruction or repair of the UCL is indicated. Historically, reconstruction, using either autograft or allograft tendon to replace the deficient UCL, otherwise known as a Tommy John procedure, has yielded reliable long-term results and remains the gold standard for surgical treatment.[1,3,7,11,12] While beyond the scope of this work, Jensen et al.[13] provide an excellent synopsis of the various surgical techniques in UCL reconstruction from Jobe's first description to modern day methods. Early literature comparing reconstruction to repair in elite athletes without regard to injury severity or tissue quality indicated superior outcomes with reconstruction.[11,14] In an early study by Conway et al.,[11] 14 baseball players (13 pitchers, one infielder) underwent direct repair of the UCL and 50% (N=7) were able to return to previous level of participation. However, within the subset of MLB players (N=7), only 29% (two of the seven) of players returned to the same level of play after UCL repair. This was in comparison to 12 of 16 (75%) MLB players who underwent reconstruction who were able to return to play at the professional level. Despite the significant discrepancy in return to play (RTP) between repair and reconstruction in professional baseball players, Conway et al.[11] noted only slightly worse results at lower levels of play (50% RTP vs. 68% RTP) with repair versus reconstruction. Recent literature however has shown promising, and in some cases superior, results with UCL repair in the properly indicated patient.[3,6,15–17]

Identification of UCL injury and subsequent surgical intervention has increased markedly in the past two decades[3,18] both in young[18,19] and professional athletes.[20] Risk factors for this trend in pitchers specifically include high pitch counts, pitching more than 100 innings per year, pitching on consecutive days, pitching for multiple teams, pitching while fatigued, pitching with higher velocity, supraspinatus weakness, geography (pitching in warmer climate), and pitching with glenohumeral internal rotation deficit (GIRD).[3,21,22] With an increasing number of procedures being performed for UCL injury, surgeons managing throwing athletes should have awareness of current surgical management options. Repair and repair with augmentation using InternalBrace (Arthrex, Naples, FL) have demonstrated results that were comparable, and in some cases superior, to reconstruction over the past 5 yr with regard to return to play, extent of downtime, and biomechanical strength.[3,6,15,23] This article will examine recent findings, techniques, and trends in the utilization of UCL repair. This work was a review of available literature, and institutional review board approval for this research was not required.

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