Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow

Abstract

Injuries to the medial ulnar collateral ligament (MUCL) can be devastating in overhead and throwing athletes. Prior to 1986, injury to this ligament was considered to be career ending. In that year, Dr. Frank Jobe reported on his initial experiences with reconstruction of the MUCL. His first case was pitcher Tommy John, who underwent what at that point was considered an experimental surgery to reconstruct the ligament using the palmaris longus tendon. The success of the classic “Tommy John” surgery in professional athletes has led most of these injuries to be managed by the same reconstructive technique. However, the injuries in young athletes do not appear to be the same as those sustained by professionals; one of the issues that led Dr. Jobe to utilize a reconstruction rather than a repair was the “wear and tear” of repetitive microtrauma rather than a discrete area of injury. Fortunately, in young athletes, the initial injury often is isolated to a single area, increasing the success of nonoperative treatment and direct repair in allowing a return to sport. Unfortunately, much of the literature continues to focus on ligament reconstruction.

As the majority of these young athletes have focal MUCL injuries isolated to one area in the proximal or distal end of the ligament without mid-substance degenerative changes, this would seemingly allow a repair rather than reconstruction. Rather than extrapolating the data of ligament reconstruction in professional athletes, we developed a protocol of repair in these younger players in an attempt to minimize morbidity and loss of time, and allow a more rapid return to sports. The indications for repair include a focal area (i.e., an injury of the proximal end, distal end, or both with or without a small fragment of bone) of ligament injury identified on both magnetic resonance imaging (MRI) and direct inspection in a patient who is at the college level or below and desires to continue throwing activity. Using these criteria, our initial study showed 93% (56 of 60) of these athletes (age range 13–23, avg. 16) returned to play (RTP) within 6 months (range 4–11.7 months) postoperatively at the same or higher level of competition. Compare this to the typical RTP after reconstruction of 83% at a mean of 11.6 months (range 3–72 months). Repair of MUCL remains a viable and underused option in the management of select MUCL injuries with excellent results and return to play in athletes.