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

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


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

In This Article

UCL Repair Techniques and Results

The quality of the native UCL tissue, timing, and anatomy of the injury are critical characteristics to consider when choosing to proceed with UCL repair. In general, acute tears with good quality tissue are amendable to repair, whereas chronic attritional tears should be treated with reconstruction.[3,6,15,17] Tear location is another important factor. Midsubstance tears of the UCL, in general have demonstrated poorer outcomes with repair when compared with proximal or distal tears or avulsions.[6,15,28]

Early UCL repair techniques utilized direct end-to-end suture repair with or without the use of bone tunnels or suture anchors.[11,35–37] Argo et al.[35] noted impressive results with UCL repair in their cohort of female athletes with 17 of 18 patients able to return to sport at a mean of 2.5 mo. Savoie et al.[36] looked at the results of UCL repairs in their case series of 60 young athletes with either proximal or distal ligamentous injury. In their series, the authors' techniques included suture plication with repair to bone drill holes or suture repair to bone using anchors. They noted good-to-excellent results in 93% of these patients. A systematic review of UCL repair outcomes by Erickson et al.[17] demonstrated excellent results with 87% of patients able to return to sport, usually within 6 mo in carefully selected patients. More recently Khalil et al.[38] published on a repair technique in pediatric overhead athletes using a single anchor.

While simple repair techniques have shown good results in some female and younger nonthrowing athletes, repair on its own may fail to meet the demands of repetitive throwing athletes especially at higher levels of competition. To address this, a novel repair with InternalBrace (Arthrex, Naples, FL) augmentation was developed and published by Dugas, et al.[39] in 2016. Early use of the technique began in 2013 by Dr. Dugas and colleagues at the American Sports Medicine Institute in Birmingham, AL.[15,17,28] The technique builds on the modern strategies for UCL primary repair with the added strength at time zero of the InternalBrace. A schematic representation of the construct can be seen in Figure 2. The procedure has shown return-to-sport rates similar to that of reconstruction with the advantage of less rehabilitation time. The decrease in healing time potentially allows the athlete to return to sport 6 mo faster than traditional reconstruction. Average return to sport for pitchers after UCL reconstruction ranges from 12 mo according to most authors;[3,28,40] however, return to prior level of play can sometime take even longer (i.e., 18 mo). Average return-to-sport time as noted by Dugas in 2019 for the InternalBrace augmented repair was 6.7 mo.[15] This has been noted to be as early as 5 mo in a study by Wilk et al.[41]

Figure 2.

Ulnar collateral ligament (UCL) repair with InternalBrace (Arthrex, Naples, FL) augmentation.

Biomechanical studies in cadavers comparing the UCL repair technique to the modified Jobe reconstruction showed similar rates of maximum torque at failure, torsional stiffness, or gap formation during failure test. However, these studies also showed greater resistance to gap formation during subfailure fatigue testing in the repair group.[39,42] Roth et al.[23] in 2021 examined the effect on joint contact mechanics in an augmented repair and a modified Jobe reconstruction technique. They noted no difference in contact pressures between the groups and no statistically significant difference from the intact state. Bachmaier et al.[43] showed similar findings in their biomechanical study comparing simple repair to augmented repair for acute UCL tear. They noted the augmented repair group had significantly higher torsional stiffness (P<0.001) and residual torque (P<0.001). They compared this to reconstruction with a modified docking technique. Fixation on the humeral side using this technique relies on placement of an interference screw as opposed to tying the sutures over a bone bridge as with the original docking technique described by Rohrbough et al.[44] They found that initial stiffness and residual torque for reconstruction was similar to the untorn state at low levels of torque, but that at sequentially higher torque levels reconstruction showed lower torque resistance leading to a completely loose state.[43] Fleisig et al.[45] examined biomechanical parameters in pitchers' status after augmented UCL repair versus native uninjured elbows in college and high school level athletes. After an average of 9.8 mo, the authors found no differences in fastball velocity or joint kinetics between the two groups.

Clinical outcomes of the augmented repair demonstrate high rates of return to sport for overhead throwing athletes. In their retrospective study in 2019 Dugas et al.[15] noted that 102 of 111 (92%) athletes who underwent augmented repair with internal brace returned to their previous level of sport or higher. Mean Kerlan-Jobe Orthopaedic Clinic Complete (KJOC) score at final follow-up was reported at 88.2. Paletta et al.[46] in 2020 reported on a series of 78 college and high school throwers with minimum 2-year follow-up who underwent augmented repair. They noted 74 of the 78 athletes (94%) returned to the same or higher level of competition at a mean of 7.5 mo postoperatively. Mean KJOC score at final follow-up in that study was 90.4.[46] Unpublished data from Savoie et al.[9] showed that 49 of 50 of their patients who underwent UCL repair with internal bracing returned to the same level of athletic competition. Remarkably, those 49 patients did so by an average of 18 wk after surgery.[9]