Torres SJ, et al. Curr Rev Musculoskelet Med. 2021;doi:10.1007/s12178-021-09698-4.
Cvetanovich and Meeks report no relevant financial disclosures.
There has been a recent increase in ulnar collateral ligament injuries. These injuries typically occur in overhead athletes and baseball players, but can occur in athletes at all competition levels.
Advances in surgical techniques have led to the reconsideration of UCL repair in appropriately selected patients with potential benefits of faster return to sport and repair of the native UCL ligament.
Injuries to the UCL have typically been treated with reconstruction, especially among high-level, professional pitchers and athletes. This continues to be the treatment of choice in this cohort or in patients with chronic tears, poor tissue quality or midsubstance tears. Although primary UCL repair has historically resulted in inferior outcomes, there has been renewed interest in this technique. Some promising data support its use in appropriately selected patients. Current studies have shown good outcomes with UCL repair with or without internal brace augmentation, including accelerated return to play with proper patient selection. An ideal patient for repair with internal brace augmentation has a UCL proximal or distal avulsion and good ligament quality has failed nonoperative treatment.
UCL repair with internal brace augmentation has shown promising results with high return to sport rates, improved functional scores and high satisfaction at 1 year among athletes. Additionally, significant complications associated with this technique with a minimum 6-month follow-up are low at 3.4%. Additional midterm and long-term outcome studies are needed to confirm the benefits of UCL repair with internal brace augmentation.
We present our surgical technique for UCL repair with internal brace augmentation and in situ ulnar nerve decompression in an amateur, non-overhead high school athlete with proximal UCL avulsion and cubital tunnel symptoms. Given the patient’s lack of ulnar nerve subluxation and his sports of football and wrestling, we performed in situ ulnar nerve decompression rather than ulnar nerve transposition. We typically would perform nerve transposition in overhead athletes with ulnar nerve symptoms, as well as patients with nerve subluxation.
The patient is a 17-year-old right-hand dominant male high school wrestler with left elbow pain. He sustained an injury 3 months prior during a “takedown” in wrestling. He extended his arm to brace a fall, hyperextended and felt a “pop.” He reports medial-sided left elbow pain and numbness and tingling in his left ring and small fingers. He returned to wrestling after the injury. Continued pain caused him to seek treatment.
He had a negative Spurling test, positive Tinel’s sign at the cubital tunnel and positive elbow compression test. He was tender to palpation at the medial elbow with diminished sensation to light touch in an ulnar nerve distribution in the fingers. Active and passive elbow range of motion was 10° to 140° with pain. There was 5-/5 strength with elbow flexion and extension, as well as pain with valgus stress. Radiographs were normal with no fracture. He was placed in a hinged elbow brace. Results of advanced imaging showed electromyography was normal. MRI of the left elbow was consistent with UCL avulsion from the medial epicondyle origin and inflammation of the ulnar nerve. His ulnar nerve symptoms resolved and he continued physical therapy and transitioned back to activities with bracing. Six months later, after extensive conservative treatment, he sustained another hyperextension injury and had similar elbow pain, as well as ulnar nerve symptoms that returned. Again, conservative treatment was employed and, after 2 weeks of rest, he resumed activity. He returned to the office 6 weeks after his second injury with continued symptoms. The patient and family were ready to proceed with UCL repair and ulnar nerve decompression with the understanding the patient would be out for the upcoming wrestling season following surgery.
Technique, nerve decompression
The patient was placed supine on the OR table with a hand table for the operative extremity. He was induced with a general anesthetic. A marking pen was used to mark the course of the ulnar nerve, as well as the medial epicondyle. An exam under anesthesia was performed. A tourniquet was placed on the operative extremity and inflated to 250 mm Hg. A 6-cm incision was made anterior to the medial epicondyle using a #15 blade.
The ulnar nerve was identified. Due to the patient’s ulnar nerve symptoms, the ulnar nerve was dissected proximally up to the arcade of Struthers. He had a thick intermuscular septum that appeared to be compressive. The nerve was released distally within the flexor carpi ulnaris (FCU) muscle and fascia (Figure 1). Care was taken to decompress the nerve without destabilizing it. The elbow was taken through a full range of motion and there was slight movement of the ulnar nerve, but no subluxation. Typically, ulnar nerve transposition is performed in overhead athletes. However, the patient is a wrestler and football player with no overhead activity and his ulnar nerve did not subluxate through a full range of motion. Therefore, we did not perform ulnar nerve transposition.
We identified the flexor pronator mass (Figure 2). The fascia was incised sharply and a muscle-splitting approach was made. The muscle mass was elevated from the UCL using a scalpel. Dissection was carried down to the medial epicondyle where the UCL injury was confirmed with an avulsion from the medial epicondyle. The UCL fibers were split in line from the avulsed portion to the sublime tubercle. The proximal insertion footprint was prepared at the medial epicondyle, drilled and tapped for insertion of a 3.5-mm SwiveLock fully threaded knotless anchor (Arthrex). Next, a free needle was used to pass the suture through the proximal UCL to repair the UCL back to its origin in a mattress configuration followed by repair of the split in the ligament (Figure 3). The insertion site of the UCL was identified on the sublime tubercle of the proximal ulna. A drill was used to create a socket, avoiding penetration of the opposite cortex. The socket was then tapped to prepare for the insertion of the non-metallic anchor. The free ends of the synthetic 2-mm tape (internal brace) from the proximal anchor were then placed in the anchor eyelet. The tension was checked and the appropriate location was marked on the internal brace suture. The SwiveLock anchor was backed up to this mark and advanced into the sublime tubercle with a varus force on the elbow (Figure 4). Next, the excess suture was sharply excised and the elbow was taken through a full range of motion to confirm isometry and appropriate tension on the internal brace augmentation. The FCU fascia was then closed in an interrupted fashion (Figure 5). After the closure of the fascia, the elbow was again taken through a full range of motion and stability of the ulnar nerve was confirmed (Figure 6).
The tourniquet was deflated; then hemostasis was achieved with electrocautery. The wound was irrigated, followed by closure in a layered fashion. A sterile dressing was applied, followed by a splint with the elbow at 90° flexion.
Our postoperative protocol includes the use of the static splint for 7 days to facilitate superficial wound healing before initiation of range of motion. During the next several weeks, increasing range of motion is obtained while the UCL repair with internal brace is protected with a functional hinged brace and avoidance of any valgus force to the elbow. During weeks 4 to 8, range of motion is gradually increased to full motion. There is a transition to include strengthening and endurance exercises beginning weeks 6 to 8. Rotator cuff and scapular movements are incorporated into the rehabilitation program. At 3 to 4 months, plyometric exercises or sport-specific exercises are added to the program. The goal is a return to sport by 6 months, but this can take up to 9 months. While participation may occur at 6 to 9 months, a return to similar preinjury performance is often 9 to 12 months following the procedure.
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- For more information:
- Gregory L. Cvetanovich, MD, associate professor of orthopedic surgery, shoulder and sports medicine at the Jameson Crane Sports Medicine Institute; and Brett D. Meeks, MD, orthopedic sports medicine fellow at The Ohio State University Wexner Medical Center, can be reached at 2835 Fred Taylor Drive, Columbus, OH 43202. Cvetanovich’s email: email@example.com. Meeks’s email: firstname.lastname@example.org.