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

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

References

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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.

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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.

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A New Technique for UCL Repair

Since we began data collection in Birmingham, Alabama in the mid 1990s, our practice has successfully treated thousands of overhead athletes of all types with the modified Jobe technique of UCL reconstruction, using either a palmaris longus tendon or a gracilis tendon graft.⁷ Until August 2013, this technique was exclusively utilized regardless of the amount and location of pathology encountered at the time of surgery. The range of pathology, from partial undersurface tearing to complete disruption of the ligament tissue, was treated by placing a graft at the anatomic insertion points of the native ligament. While the success of this experience cannot be overlooked, we also realized that we were treating a broad spectrum of pathology and injury with the same operation.

Recognizing the valuable contributions of earlier authors who had attempted UCL repair previously, we asked whether we were doing too much of an operation for all of the various pathology we saw at the time of surgery, and 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 in order to achieve an equal or superior outcome in less time. In particular, could such a technique be applied to the ever-increasing number of younger athletes with less pathology, who more frequently suffer end-avulsions and partial tears of their UCL?

These thoughts, along with Savoie and colleagues’¹³ experience with UCL repair using suture anchors, 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. The construct includes an ultra-strong collagen coated tape (FiberTape, Arthrex) attached at the anatomic insertions of the ligament using two 3.5-mm nonabsorbable PEEK corkscrew anchors (SwiveLock, Arthrex), and a suture through the eyelet of one of the anchors (Figure 1). Using this construct, the native ligament disruption can be repaired directly to bone using the suture through the eyelet of the anchor, and the remainder of the native ligament is augmented with the spanning biologic enhanced tape (Figures 2A-2C). The construct is created by placing one end of the tape through the eyelet of the first anchor, and then placing one end of a No. zero braided permanent suture through the same eyelet. Both ends of the tape are then placed through the eyelet of the second anchor. The first anchor is inserted into a hole drilled at the apex of the insertion of the torn end of the native ligament. This anchor is placed first in order to allow for direct repair of the native torn ligament using the free suture through the eyelet of the first anchor. The second hole is then drilled at the insertion of the native ligament on the uninjured end of the native ligament. In order to accommodate the volume of tape in the hole created for the second anchor, a slightly oversized drill and tap were created specifically for this technique (Arthrex).

Before attempting this in vivo, a cadaveric study was carried out in order to ensure that the time-zero function of the construct would be at least as good as the standard UCL reconstruction technique we have used for several decades.¹⁴ The time-zero gap formation under valgus load was less for the repair/augmentation than for the standard reconstruction with palmaris longus, and the ultimate failure strength of the repair was the same as in the reconstruction group, with all failures through bone in the cadaveric specimens. No anchors pulled out of bone, and the tape did not tear in any specimen.

This basic science study has given us confidence to proceed with the use of this technique in patients. The first patient was treated with this construct in August 2013. The outcomes of our first series of patients were presented on Saturday, March 5 at American Orthopaedic Society for Sports Medicine Specialty Day during the 2016 American Academy of Orthopaedic Surgeons annual meeting in Orlando, FL.

We do not feel that this technique is adequate for the treatment of the UCL that has sustained attritional injury and contains poor quality native ligament tissue. Before we do these procedures, we always discuss with the patient the possibility that full reconstruction may be required, and that the decision to proceed with UCL repair is contingent upon the quality and quantity of the native UCL tissue present at the time of surgery. If the quality of the native tissue is poor (chronic degenerative changes, etc), full reconstruction with autograft tendon is recommended. It is our hope that this technique will afford the UCL surgeon another option for treating end-avulsions and partial thickness injuries, with a more rapid and successful return to normal function and competition.