Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up

Abstract

The ulnar collateral ligament (UCL) is the primary restraint to valgus angulation at the elbow. Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing. Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation. Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. Here we present the first patient treated with this technique who achieved excellent recovery with return to college level American Football after 4 months. Five years later he has good elbow function and plays at the same level.

Background

The ulnar collateral ligament (UCL) is a stabiliser of the medial side of the elbow with its anterior band acting as the primary restraint to valgus angulation.^1–3 Injury to the UCL can be caused by trauma resulting in extreme valgus angulation or dislocation of the elbow joint.^4–9 However, it is more often a result of repetitive valgus forces on the elbow causing structural damage and chronic injury to the UCL.⁸ For this reason, the injury is common in young athletes involved in overhead throwing sports, particularly pitchers in baseball and quarterbacks in American Football.^{6 10} Biomechanical studies have shown the valgus forces to be as high as 64 Nm during pitching which exceeds the ultimate tensile strength of the UCL, hence when dynamic muscular stabilisers become fatigued, there is a high risk of injury.¹¹ Indeed, this type of injury is becoming significantly more common, particularly in young overhead throwing athletes of all levels.8 10 12–14 As a result, prevention strategies have been implemented but the treatment of the condition still remains controversial.¹⁵ Non-operative treatment can be considered initially in young patients with acute avulsions. However, in many cases where the torn ligament is attenuated or does not heal, chronic valgus instability can occur with an inability to return to throwing sports.4–7 16 17

In 1986, Jobe et al described the first technique for reconstruction of the UCL using tendon autograft,¹⁸ and modifications of this technique remain the gold standard treatment to the present day.⁸ This technique, known as Tommy John surgery after the first major league baseball player to have this done, has been widely practised and there are several reports on outcomes in the literature.¹⁹ Rates of return to the sport have ranged from 66% to 97% based on the athlete’s level of competition and surgical technique.^20–24 Time out of sport following this type of surgery can be up to 1 year.²⁵

Surgical repair of the UCL rather than reconstruction had been performed but was largely abandoned as a method with a return to sport rate estimated at 71%.²⁶ However, with the rising incidence of injury, more demand for a quicker return to high-level sport and the advent of modern surgical instrumentation, the idea of repair has been explored again.^{27 28}

We present a case of a novel repair method for the UCL, augmented by an internal brace to provide stability against excessive angulation in the early stages.²⁸ We detail his injury, treatment, recovery and function up to 5 years following the surgery.

Case presentation

In this study, we follow the case of a 25-year-old college level Quarterback American Football player who sustained a traumatic elbow dislocation during a game in October 2012, when he landed awkwardly during a tackle. This was a closed injury and there was no sign of nerve or vascular injury found on physical examination. It occurred when abroad and he underwent reduction under sedation in a European emergency department. He was otherwise fit and well and had no previous injury to the elbow.

On return, following 1 week of immobilisation in a cast, he was reviewed in the local orthopaedic clinic. Grade III clinical valgus laxity was found on physical examination. MRI scanning confirmed the presence of a complete tear of the UCL from the proximal insertion on the humerus with disruption of the common flexor origin (figure 1). There was no associated fracture.

Figure 1.

MRI scan (coronal T2-weighted slice) showing ruptured UCL of the elbow (indicated by yellow arrow). UCL, ulnar collateral ligament.

He was advised non-operative management and commenced a physiotherapy programme, consisting primarily of a simple range of movement exercises of the elbow, followed by isometric and dynamic strengthening.

Three months later, the range of movement had improved to preinjury level but he was still experiencing persistent medial instability and was referred to a sports medicine specialist. Repeat MRI scan revealed the persistent lack of continuity of the fibres of the UCL at the proximal origin.

Treatment

As a result of persistent instability after 3 months of conservative management, the decision was taken to operate on the UCL. To the authors’ best knowledge, this patient was one of the first people to be treated with primary repair of the UCL and augmentation with an internal brace. This technique involves primary repair of the ligament with size 0 non-absorbable suture and augmenting the repair with FiberTape (Arthrex), held with two non-absorbable knotless anchors placed at the anatomic central footprint of the ligament proximally and distally (figure 2).

Figure 2.

Schematic diagram illustrating repair of UCL and augmentation with InternalBrace (Arthrex). UCL, ulnar collateral ligament.

Outcome and follow-up

We followed the case prospectively over a 5-year period to assess patient satisfaction, function and sporting performance. The patient recovered extremely well after the surgery, having regained full range of movement and a perceived increase in elbow stability on review after 2 weeks. He wore no external bracing postoperatively and commenced a strengthening programme at 2 weeks once the wound was healed. He returned to contact training at 8 weeks postsurgery and resumed competition at the preinjury level at 3 months. Now 5 years on, he has experienced no complications and has a fully functioning, stable elbow with no symptoms, allowing him to continue playing American Football at the same level.

Discussion

Surgical reconstruction of the UCL is the most common procedure to manage valgus instability of the elbow, with around 800 performed in the USA annually.¹⁴ The average age of the patient is approximately 20 years and the majority are athletes involved in throwing sports from recreational to professional levels.¹⁴

In the largest study of its kind, Cain et al ¹⁹ assessed the clinical outcome of 1281 patients who underwent a modified Jobe UCL reconstruction. They found that 83% of athletes returned to their preinjury level of play or higher and that the average time to return to full competition was almost 1 year. Additionally, there was a relatively high (20%) minor complication rate.¹⁹

Over 30 years ago, early work on primary UCL repair demonstrated disappointing results, with Conway et al ²⁶ and later Azar et al ²¹ showing that only 50% and 63% respectively were able to return to their previous level of activity. More recently, promising results have emerged regarding the primary repair of the UCL, particularly focusing on young athletes with either proximal or distal avulsions.^27–29 Savoie et al ²⁹ demonstrated that 97% returned to their sport at the same level or higher within 6 months when acute UCL tears were repaired in adolescents. Other studies have shown return to play rates of 82%–94% again within quicker time frames and largely using modern suture anchors.^{9 30}

The internal brace concept augments the primary surgical repair, using high strength suture tape appropriately tensioned across the construct such that it protects the repair if excessive force is a placed across it.^{31 32} Similar techniques have been used in repairs at several other joints, such as the knee, where it has been used in the repair of the anterior cruciate ligament and collateral ligaments.^{32 33} It has also been used with good success in the foot and ankle, permitting aggressive early rehabilitation.31 32 34 35

Augmentation of the repair with an Internal Brace protects the healing ligament while allowing early rehabilitation and accelerated return to play.²⁰ Furthermore, this technique preserves the native anatomy and potentially retains proprioception, which may improve function and reduce the risk of future injury.²⁸ It also carries less morbidity through graft harvesting and drilling of bone tunnels, as is required with reconstruction.^{20 28} In a recent biomechanical study, Dugas et al ²⁷ found that when compared with specimens that underwent modified Jobe reconstructions, cadaveric specimens undergoing repair with internal brace augmentation demonstrated similar characteristics including ultimate failure strength, gap formation and valgus stability. One important consideration during the insertion of the internal brace is not to overtension the suture tape, as this could lead to problems with overconstraint of the medial elbow. As with other joints where this technique is employed, the elbow is put through a full range of movement and valgus stability tested prior to fully tightening the anchor.³⁶

To the authors’ best knowledge, this is the first case following long-term outcome after primary UCL repair with internal brace augmentation. The patient noticed a significant improvement in the function and stability of his elbow immediately following the surgery. This novel technique gave both the patient and clinicians the confidence to commence accelerated rehabilitation after only 2 weeks, and he was back playing throwing the ball and contact training after 2 months. He regained preinjury sporting level by 3 months and 5 years on is still playing with no symptoms of pain or instability at his elbow.

In conclusion, we present the first patient treated with this novel technique of primary UCL repair with internal brace augmentation. He achieved excellent recovery with return to college level American Football at 3 months and 5 years later has good elbow function and plays at the same level. Future work is required to quantify functional recovery following ligament repair surgery compared with reconstruction, in order to investigate the potentially retained proprioception.

Patient’s perspective.

I hyperextended my elbow during a football game and then had a lot of pain and instability before I had the surgery. The rehab time was minimal, I remember wearing a sling for a few weeks only. I am stronger in some exercises than before, for example I can do a dumbbell curl with a heavier weight than before the injury. I might have had some residual pain after games/training but not to a point where it bothered me. Now over 5 years since surgery, my function is good and I play American Football for a league team in Georgia.

Learning points.

• Injury to the ulnar collateral ligament of the elbow is common in overhead throwing sports leading to valgus instability.

• Traditional treatment is surgical reconstruction but return to play rates and timing are variable.

• Primary repair with internal brace augmentation emerging as a promising alternative.

• Allows for a quicker return to play and retained proprioception.

• Five-year follow-up shows excellent function with no complications.