Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes

Abstract

Context: Ulnar collateral ligament (UCL) injuries lead to pain and loss of performance in the thrower's elbow. Ulnar collateral ligament reconstruction (UCLR) is a reliable treatment option for the symptomatic, deficient UCL. Injury to the UCL usually occurs because of chronic accumulation of microtrauma, although acute ruptures occur and an acute-on-chronic presentation is also common.

Evidence acquisition: Computerized databases, references from pertinent articles, and research institutions were searched for all studies using the search terms ulnar collateral ligament from 1970 until 2015.

Study design: Clinical review.

Level of evidence: Level 5.

Results: All studies reporting outcomes for UCLR are level 4. Most modern fixation methodologies appear to be biomechanically and clinically equivalent. Viable graft choices include ipsilateral palmaris longus tendon autograft, gracilis or semitendinosus autograft, and allograft. Clinical studies report excellent outcomes of UCLR for both recreational and elite level athletes with regard to return to sport and postoperative performance. Complications, although rare, include graft rerupture or attenuation, ulnar nerve symptoms, stiffness, pain, and/or weakness leading to decreased performance.

Conclusion: Injuries to the UCL have become commonplace among pitchers. Nonoperative treatment should be attempted, but the limited studies have not shown promising results. Operative treatment can be performed with several techniques, with retrospective studies showing promising results. Complications include ulnar neuropathy as well as failure to return to sport. Detailed preoperative planning, meticulous surgical technique, and a comprehensive rehabilitation program are essential components to achieving a satisfactory result.

Keywords: Tommy John; biomechanics; elbow; instability; pitcher; surgical management; throwing athlete; ulnar collateral ligament reconstruction.

Figure 1.

(A) Anatomy of the ulnar collateral ligament (UCL). (B) Magnetic resonance image demonstrating a tear of the UCL at the tip of the arrow.

Figure 2.

Valgus stress test. The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress about the elbow. The valgus stress test is used to evaluate the anterior bundle of the UCL and is performed with the patient sitting or supine and the forearm held between the examiner’s trunk and forearm. This is similar to a varus/valgus stress test of the knee. The patient is placed in a (A) standing or (B) supine position. The elbow is flexed to 20° to 30°, which removes the osseous constraint of the ulnohumeral joint, and a valgus stress is applied. During this maneuver, the examiner palpates along the course of the UCL, with tenderness or laxity without a firm endpoint indicating a UCL injury. A small side-to-side difference in laxity can be normal in pitchers^, (see Video 1, available at http://sph.sagepub.com/content/by/supplemental-data).

Figure 3.

Milking maneuver. This test evaluates the posterior band of the anterior bundle of the ulnar collateral ligament (UCL) and is performed with the forearm supinated, shoulder extended and externally rotated, and elbow flexed at 90°. The examiner pulls the patient’s thumb, thereby generating a valgus stress at the elbow. Pain and apprehension with the maneuver is indicative of a UCL injury. Video supplement available online (Video 2, available at http://sph.sagepub.com/content/by/supplemental-data).

Figure 4.

Moving valgus stress test. This test is performed with the shoulder abducted to 75°. The examiner maximally flexes the elbow and externally rotates the shoulder and exerts a constant valgus load to the elbow as the elbow is extended quickly to 30°. The test, reported to be 100% sensitive and 75% specific, is positive when the pain generated during the examination mimics the medial elbow pain on throwing and when the pain is most significant between 120° and 70° (referred to as the shear range) as the elbow is extended. This correlates with the late cocking/early accelerations phases (Video 3, available at http://sph.sagepub.com/content/by/supplemental-data).

Figure 5.

(A) Intraoperative photograph demonstrating the standard docking technique. The graft has been passed through a tunnel created in the ulna and is being prepared to be docked into the medial epicondyle. Notice the 2 strands of the palmaris longus autograft that are available to be docked into the medial epicondyle. A cricket is used to maintain exposure. (B) Intraoperative photograph demonstrating the double-docking technique. The hamstring autograft has been docked into the ulna and is being prepared to be docked into the medial epicondyle. Notice the gapping present at the ulnohumeral joint, indicating an incompetent ulnar collateral ligament.