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Ulnar Collateral Ligament Repair: An Old Idea With a New Wrinkle

Am J Orthop. 2016 March;45(3):124-127

At our practice, we have successfully treated thousands of overhead athletes with the modified Jobe technique of ulnar collateral ligament (UCL) repair. We used this technique regardless of the amount and location of the pathology encountered at the time of surgery. We asked whether the availability of modern anchor and suture technology, vast clinical experience with these injuries and their outcomes, and even biologic additives could be applied to some of these patients to achieve an equal or superior outcome in less time. This led us to create a construct that could be used to not only repair the torn native UCL tissue to bone, but also span the anatomic native ligament from its origin to its insertion. This construct includes an ultra-strong collagen coated tape attached at the anatomic insertions of the ligament using two 3.5-mm nonabsorbable PEEK corkscrew anchors and a suture through the eyelet of one of the anchors.

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References

1. Norwood LA, Shook JA, Andrews JR. Acute medial elbow ruptures. Am J Sports Med. 1981;9(1):16-19.

2. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am. 1986;68(8):1158-1163.

3. Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes: treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74(1):67-83.

4. Azar FM, Andrews JR, Wilk KE, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med. 2000;28(1):16-23.

5. Ahmad CS, Lee TQ, ElAttrache NS. Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation. Am J Sports Med. 2003;31(3):332-337.

6. Armstrong AD, Dunning CE, Ferreira LM, Faber KJ, Johnson JA, King GJ. A biomechanical comparison of four reconstruction techniques for the medial collateral ligament-deficient elbow. J Shoulder Elbow Surg. 2005;14(2):207-215.

7. Cain EL, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426-2434.

8. Paletta GA, Klepps SJ, Difelice GS, et al. Biomechanical evaluation of 2 techniques for ulnar collateral ligament reconstruction of the elbow. Am J Sports Med. 2006;34(10):1599-1603.

9. Ruland RT, Hogan CJH, Randall CJ, Richards A, Belkoff SM. Biomechanical comparison of ulnar collateral ligament reconstruction techniques. Am J Sports Med. 2008;36(8):1565-1570.

10. Dugas JR, Ostrander RV, Cain EL, Kingsley D, Andrews JR. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007;16(5):657-660.

11. Argo D, Trenhaile SW, Savoie FH, Field LD. Operative treatment of ulnar collateral ligament insufficiency of the elbow in female athletes. Am J Sports Med. 2006;34(3):431-437.

12. Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med. 2003;32(5):1158-1164.

13. Savoie FH, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36(6):1066-1072.

14. Dugas JR, Walters BL, Beason DP, Fleisig GS, Chronister JE. Biomechanical comparison of ulnar collateral ligament repair with internal bracing versus modified Jobe reconstruction. Am J Sports Med. 2015. [Epub ahead of print].

Repair of the ulnar collateral ligament (UCL) was first reported by Norwood and colleagues¹ in a group of athletes who sustained acute UCL ruptures. Of the 4 athletes in their cohort who underwent direct UCL repair, none were noted to have any residual instability 2 years after the surgery. However, none of these 4 were overhead throwing athletes. Jobe and colleagues² first published Jobe’s technique of UCL reconstruction in 1986, but it was Conway and colleagus’³ 1992 publication describing Jobe’s experience with UCL injury and surgical treatment in throwing athletes that set the early standard for management in that population. Since those landmark studies, there has been a tremendous increase in attention to this near-epidemic clinical problem.

Although these studies were the first to describe the surgical procedure that is now often referred to as “Tommy John surgery,” named after Jobe’s initial patient in 1974, Conway and colleagues³ also reported on Jobe’s early experience with UCL repair. In fact, of the 70 patients reported in the Conway and colleagues’³ article, 14 were treated with repair of the ligament. Only 7 of the 14 (50%) of those who underwent UCL repair were able to return to the same level of play, and only 2 of the 7 (29%) of Major League Baseball (MLB) players who underwent UCL repair were able to return to competition at the MLB level. This compared very poorly with the nearly 75% rate of return to competition in patients who underwent UCL reconstructions in the same cohort. In Azar and colleagues’⁴ 2000 report on Dr. James Andrews’ experience with UCL injury and treatment in male college and professional baseball players, UCL repair again did poorly when compared to UCL reconstruction, with only 5 of the 8 (63%) of UCL repair patients returning to the same level of play compared to 41 of the 51 (81%) of UCL reconstructions using a modification of Jobe’s original technique.

Since the mid-1990s, numerous new techniques have been described and shown to have acceptable and largely successful outcomes in treating UCL injuries.^5-9 All of them involve placing or anchoring a spanning piece of tendon graft from the native origin on the medial epicondyle of the humerus to the native insertion on the sublime tubercle of the ulna. These palpable and visible anatomic landmarks are important to the UCL surgeon due to the need to place the graft or repair the torn ligament tissue to its normal anatomic origin and/or insertion.¹⁰ Regardless of whether the graft is sewn, docked, tunneled, or anchored, these types of procedures have demonstrated rates of return to competition at the same or higher level of play in the 75% to 92% range.^3,4,7,11-13In the largest published series of 1281 UCL reconstructions by Cain and colleagues⁷ at American Sports Medicine Institute (Birmingham, AL), the rate of return to play at the same or higher level was 84%, with the average time to return to play of 11.4 months. On the basis of these robust clinical studies and numerous basic science studies demonstrating essentially equivalent strength and function among reconstruction techniques, UCL reconstruction now enjoys an acceptance among clinicians, athletes, athletic trainers, coaches, and team management at all levels of overhead sports.

In comparison to UCL reconstruction, relatively little has been published on UCL repair since 2000. Certainly this is in part due to the success of its clinical descendant. UCL repair did not appear on the pages of peer-reviewed literature until 2006, when Argo and colleagues¹¹ published a report on the outcome of 17 UCL repairs in female athletes using a variety of techniques, including plication, anchor-to-bone, and drill holes. Although there was only 1 pitcher in the group, 16 of the 17 (94%) returned to the same or higher level of competition at an average of only 3 months after surgery.¹¹

Savoie and colleagues¹³ followed this in 2008 with a report on 60 UCL repairs in overhead athletes. Of the 51 patients in this study in which the ligament was repaired to bone using suture anchors, 93% returned to the same or higher level of play at an average of only 6 months after surgery. Including Jobe’s original group, there have been less than 100 patients ever reported to have had a UCL repair performed. In comparison to the thousands of UCL reconstructions that have been reported over the last 20 years, it is not surprising that UCL repair has not gained great popularity among surgeons and patients. It is also important to remember that suture and anchor technology has come a long way since the 1970s, and our overall knowledge of the injury and its treatments and rehabilitation have grown tremendously since that time.