Tips for Successful Ulnar Collateral Ligament Reconstruction

Ulnar collateral ligament (UCL) reconstruction has become an increasingly common procedure in overhead-throwing athletes because of overuse and repetitive valgus stress placed on the inside of the elbow or valgus stress during an acute traumatic event². Athletes with a deficient UCL often report a decrease in pitch velocity and accuracy in addition to an increase in fatigue, pain, and instability⁴. As such, UCL reconstructive procedures have been increasing in prevalence in throwing athletes to address their symptoms and regain their throwing capabilities, particularly in young baseball players at the high school and collegiate levels¹.

For the present video article, a hamstring autograft was chosen because of its availability in all patients and its noninferior outcomes reported in the literature. Following gracilis graft harvest, the reconstruction begins centered on the medial epicondyle with the patient in a supine position. The ulnar nerve is identified and freed both proximally and distally. The split is extended distally through the heads of the flexor carpi ulnaris. From the base of the flexor carpi ulnaris, the sublime tubercle is identified, and the UCL is opened inline. A standard guide is utilized to drill holes in both the posterior and anterior aspects of the sublime tubercle. These holes are then connected with use of a curved curet, and a suture is passed along the tunnels for later graft passage. A blind-ended tunnel is drilled at two-thirds of the distance from the tip to the base of the epicondyle. Two smaller tunnels are then drilled with Kirschner wires to allow passing sutures through the posterior aspect of the epicondyle. The native UCL is closed, and the graft is passed through the sublime tubercle tunnels. One end of the graft is docked into the epicondylar tunnel, and a docking procedure is performed so that both ends of the graft are docked within the humeral tunnel. Stay sutures are tied over a bone bridge, and the 2 limbs of the graft are sutured together to appropriately tension the graft.

Although nonoperative treatments with a hinged elbow brace may be appropriate in low-demand patients, reconstruction is preferred in high-volume throwers with future hopes of returning to play. Nonoperative treatment may involve rest, physical therapy, and a graduated throwing program in addition to biologic injections.

The present video article includes a checklist of the senior author's top 10 key steps for a successful UCL reconstruction with hamstring autograft, which can be utilized to guide surgeons through the steps of the procedure. This procedure is preferred for patients with substantial throwing pain and a strong desire to return to a high level of throwing, as many who discontinue sport may be able to perform normal activities of daily living even with an insufficient ligament.

Successful reconstruction of the ligament results in high rates of return to play and favorable patient-reported outcomes, as well as low rates of revision surgery³. Our experience at Rush has seen 94% of athletes return to their previous level of play, as well as excellent Kerlan-Jobe Orthopaedic Clinic (KJOC) scores (90.4) and Andrews-Timmerman scores (92.5)¹.

Preserve the medial antebrachial cutaneous nerve during initial exposure and position the posterior portion of the incision more distally in order to avoid its major branches.Split the flexor more distally than during traditional ulnar nerve transposition in order to allow for access to the sublime tubercle.Open the joint and visualize the joint line in order to approximate the position of the ulnar tunnels. The joint line is often more distal than you may think.If the ligament is torn either proximally or distally, incorporate repair sutures into the tunnels in order to perform a primary repair along with reconstruction.Always be mindful of the ulnar nerve when drilling tunnels, and minimize its handling. Generally, the nerve is retracted posteriorly for sublime tunnel drilling.As it approaches the sublime tubercle, the ulnar ridge approximates the center of the tubercle.Failure to resect medial olecranon osteophytes can result in continued elbow pain. Preoperative computed tomography can help in identifying any notable osteophytes.Begin drilling the humeral tunnel with use of a small, sharp-tipped drill, such as a 3.5-mm drill, which will allow you to precisely position the tunnel without causing drill walking. You can dilate up the drill size as you progress.Reduce the joint during ligament repair, and secure the graft in a varus position at 45° to 60° of flexion.Try to bury the knot adjacent to the medial epicondyle. The knot can be prominent, and patients can feel it.Tunnels should be spaced at least 1 cm apart in order to avoid violating the osseous bridge.Ensure secure anterior transposition of the ulnar nerve at the end of the procedure. We prefer subcutaneous transposition to avoid any potential incarceration of the nerve.

KJOC = Kerlan-Jobe Orthopaedic ClinicUCLR = ulnar collateral ligament reconstructionROM = range of motionRTS = return to sportFCU = flexor carpi ulnarisPROM = passive range of motionFE = flexion-extensionEX = exercisePT = physical therapy or physical therapistAAROM = active-assisted range of motionUE = upper extremityFU = follow-upRTP = return to playRTPP = return to previous play or position (sometimes used as "return to pre-injury performance," depending on context).