The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 8

Scientific Articles | April 18, 2012

Ulnar Collateral Ligament Reconstruction in Throwing Athletes: A Review of Current Concepts: AAOS Exhibit Selection

Kristofer J. Jones, MD¹; Daryl C. Osbahr, MD²; Mark A. Schrumpf, MD¹; Joshua S. Dines, MD¹; David W. Altchek, MD¹

¹ Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.J. Jones: kjjonesmd@gmail.com. E-mail address for M.A. Schrumpf: schrumpfm@hss.edu. E-mail address for J.S. Dines: jdinesmd@gmail.com. E-mail address for D.W. Altchek: altchekd@hss.edu
² Department of Orthopaedic Surgery, American Sports Medicine Institute, 2660 10th Avenue, Suite 505, Birmingham, AL 35205. E-mail address: osbahrd@gmail.com

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Investigation performed at the Hospital for Special Surgery, New York, NY

J Bone Joint Surg Am, 2012 Apr 18;94(8):e49 1-12. doi: 10.2106/JBJS.K.01034

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Isolated ulnar collateral ligament (UCL) injury from repetitive throwing was first described by Waris in 1946 in javelin throwers¹. Although these injuries were once considered career-ending for athletes, a surgical technique pioneered by Jobe in 1974 facilitated successful return to competition². Since that time, modifications of the original procedure have resulted in improved clinical results. The present article provides a comprehensive review of current concepts related to UCL injury in throwing athletes, including a review of relevant anatomy and biomechanics, the mechanism of UCL injury and associated elbow pathology, and the evolution of UCL reconstruction procedures and clinical outcomes.

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Introduction

Overview of UCL Anatomy

The UCL is composed of three bundles: anterior, posterior, and oblique; the oblique bundle is commonly termed the transverse ligament^3,4 (Fig. 1). Gross anatomical studies have demonstrated that the anterior bundle is easily distinguished from the underlying joint capsule^5,6. The anterior bundle consists of two separate histological layers: the deeper layer is composed of collagen bundles contained within the capsule, and the shallower layer is a distinct ligamentous structure superficial to the capsule⁷. The anterior bundle originates from the anteroinferior edge of the medial humeral epicondyle and inserts onto the sublime tubercle of the ulna. There is a distinct ridge on the sublime tubercle that divides the anterior bundle into two equally sized bands, the anterior and posterior bands^5,6 (Fig. 2). The area of the origin of the anterior bundle on the medial humeral epicondyle is 45.5 ± 9.3 mm², whereas the insertion on the sublime tubercle is much broader, measuring 127 ± 35.7 mm² (Fig. 3)⁶.

Fig. 1

Anatomy of the ulnar collateral ligament. (Reproduced from: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74:67-83.)

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Fig. 2

Origin of the anterior bundle dissected from its osseous attachment on the medial humeral epicondyle. (Reproduced, with permission from Elsevier, from: Dugas JR, Ostrander RV, Cain EL, Kingsley D, Andrews JR. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007 Sep-Oct;16[5]:657-60. Copyright [2007]. http://www.sciencedirect.com/science/journal/10582746.)

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Fig. 3

Insertion of the anterior bundle dissected from its osseous attachment on the medial ulna. Note that the attachment site extends distal to the sublime tubercle. (Reproduced, with permission from Elsevier, from: Dugas JR, Ostrander RV, Cain EL, Kingsley D, Andrews JR. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007 Sep-Oct;16[5]:657-60. Copyright [2007]. http://www.sciencedirect.com/science/journal/10582746.)

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The posterior bundle originates from the posteroinferior aspect of the medial humeral epicondyle and has a broad insertion on the medial edge of the olecranon. The posterior bundle is not easily distinguished, as it consists of a single layer of collagen bundles within the posteromedial aspect of the capsule^7,8. The transverse ligament is variable in both size and gross appearance, as it extends from the inferomedial margin of the coronoid process to the medial edge of the olecranon⁹.

Functional Biomechanics of the UCL

The anatomical structure that provides the predominant contribution to valgus stability of the elbow varies according to the degree of elbow flexion. Intrinsic osseous restraint between the olecranon and the trochlea provides the predominant contribution to valgus stability at <20° or >120° of elbow flexion^10,11. The anterior bundle of the UCL serves as the primary static stabilizer to valgus stress from 20° to 120° of elbow flexion^10-14. A cadaveric study by Callaway and Warren indicated that the anterior band of the anterior bundle was the primary restraint to valgus rotation at 30°, 60°, and 90° of flexion and shared this role with the posterior band at 120° of flexion¹⁵. The anterior band was more susceptible to valgus overload than the posterior band when the elbow was in extension or at a low flexion angle, and the posterior band was more susceptible when the elbow was at higher flexion angles. However, other authors have found that the posterior bundle served as a secondary stabilizer at high degrees of flexion^16,17. Pollock et al. demonstrated that posterior bundle sectioning resulted in a 3.5° (30%) increase in maximum varus-valgus laxity and a 1° (29%) increase in maximum internal rotation during pronated active flexion, which suggests that the posterior bundle may be important in the late cocking phase of throwing¹⁸. In contrast with the anterior and posterior bundles, the transverse ligament does not play an important role in elbow stability as it does not span the ulnohumeral joint¹⁹.

Kinetics of the Overhead Throw: Understanding Mechanisms of Injury

The overhead throw has been divided into six phases: windup, early arm-cocking, late cocking, acceleration, deceleration, and follow-through (Fig. 4)^20–25. The late cocking phase produces tremendous valgus torque that is generated by forward rotation of the upper trunk and pelvis and external rotation of the shoulder. Aguinaldo and Chambers demonstrated that the magnitude of valgus torque at the elbow is heavily influenced by maximum shoulder external rotation. Throwing mechanics that incorporated late trunk rotation, reduced shoulder external rotation, and increased elbow flexion were found to be protective as they reduced valgus torque²⁶. In order to oppose this potentially injurious valgus torque, a 64 ± 12 N-m varus torque is generated during the acceleration phase²⁴. This phase is characterized by maximum elbow extension velocity, measuring 2100°/s to 2700°/s²⁵. The deceleration phase is initiated at ball release and is completed as the shoulder approaches a position of maximum internal rotation. Elbow extension is typically completed 20° short of full extension, and the flexor-pronator musculature aids in preventing posteromedial impingement of the olecranon^24,25.

Fig. 4

The six stages of the overhead throw. (Reproduced, with permission from Elsevier, from: DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the upper extremity in pitching. J Shoulder Elbow Surg. 1992;1[1]:15-25, Copyright [1992]. http://www.sciencedirect.com/science/journal/10582746.)

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Valgus stress from throwing can produce three distinct pathologic forces at the elbow: (1) a tensile force to medial stabilizing structures, (2) a compressive force at the radiocapitellar joint, and (3) a medially directed shear force in the posterior compartment. Morrey demonstrated that the UCL produces 54% of the varus torque that is required to oppose valgus load at 90° of flexion¹². During the acceleration phase, maximum valgus torque can reach 64 N-m; this exceeds the ultimate tensile strength of the UCL (32.1 ± 9.6 N-m), leading to attritional changes²⁴.

Dynamic stabilizers including the flexor-pronator mass are also prone to injury during throwing. Some authors propose that the flexor carpi ulnaris serves as the primary dynamic stabilizer to valgus stress at the elbow because of its position in line with the UCL²⁷. The flexor digitorum superficialis and the flexor carpi radialis serve as secondary dynamic stabilizers, and the pronator teres makes a smaller contribution to valgus stability^27,28. These dynamic stabilizers are exposed to increased stress if the UCL becomes attenuated, resulting in medial epicondylitis and/or flexor-pronator tendon tears. Flexor-pronator mass injury has been reported to accompany 4.3% to 12.8% of UCL injuries^29,30. Osbahr et al. identified age as a significant risk factor for combined UCL and flexor-pronator mass tears, as seven of eight baseball players with combined injuries were more than thirty years of age²⁹.

The ulnar nerve is also predisposed to injury if UCL attenuation has occurred. Aoki et al. measured longitudinal movement and strain of the ulnar nerve during throwing³¹. A maximum strain of 13.1% was observed at the cubital tunnel during the early acceleration phase; this strain value approximates the elastic limits of the ulnar nerve and its associated vascular supply, suggesting that repetitive strain from throwing may cause intraneural injury and ischemia resulting in ulnar neuritis.

During the late cocking and early acceleration phases of throwing, compressive forces measuring 500 N have been observed at the radiocapitellar joint²⁴. Pathologic overloading can result in radiocapitellar chondromalacia, cartilage degeneration, and eventually osteochondral fracture and formation of intra-articular loose bodies. A recent study by Momma and colleagues demonstrated greater bone density in the posterior aspect of the trochlea and the anterior aspect of the capitellum in baseball pitchers compared with players at other positions³². The authors concluded that these findings represented an adaptation of subchondral bone to repetitive valgus stress from pitching³², thus underscoring the role of mechanical conditions in capitellar osteochondritis dissecans³³.

Valgus extension overload represents a spectrum of injury that occurs from abnormal contact between the posteromedial aspect of the olecranon process and the olecranon fossa^34–37. During normal kinematics, the flexor-pronator mass contracts throughout the acceleration phase to prevent elbow distraction at ball release and to generate a decelerating force that limits elbow extension and prevents impingement between the olecranon and the olecranon fossa^24,25. If the UCL or the dynamic flexor-pronator musculature is incompetent, elbow extension and valgus torque can result in posteromedial impingement with subsequent chondromalacia and osteophyte formation^36,37. Pathologic contact can also result in olecranon stress fractures that have a characteristic oblique pattern. These stress fractures have been reported in baseball players and javelin throwers^1,38.

A recent cadaveric study by Osbahr et al. introduced the concept of ulnohumeral chondral and ligamentous overload to describe abnormal contact between the medial tip of the olecranon and the medial crista of the humeral trochlea at high flexion angles³⁹. The authors observed that sectioning of the anterior bundle of the UCL resulted in increased posteromedial contact pressures during simulated early acceleration. The results of that study suggest that the valgus overload responsible for the characteristic posteromedial elbow pathology seen in patients with UCL laxity may occur throughout the entire throwing motion rather than only with elbow extension.

Evaluation of the Throwing Athlete

History

Comprehensive evaluation of a throwing athlete with elbow pain should begin with a focused history. Information regarding the athlete’s sport, level of participation, and recent alterations in training regimen (e.g., pitch count, number of innings pitched, and types of pitches) should be clarified. The specific throwing phase that exacerbates symptoms may also provide diagnostic clues²⁴. A history of prior shoulder injury may indicate an alteration in throwing mechanics resulting in pathologic motion at the distal aspect of the kinetic chain.

UCL tears can be acute, chronic, or acute-on-chronic injuries. An athlete with an acute injury may describe a sudden onset of medial elbow pain accompanied by a “popping” sensation. A long-standing history of medial elbow discomfort with overhead throwing, particularly during the late cocking and early acceleration phases, may represent a chronic UCL injury. An athlete with such an injury will often complain of substantial changes in throwing accuracy and velocity as well as diminished stamina and strength. Vascular complaints, cold intolerance, and numbness or tingling that radiates to the ring and small fingers may represent ulnar neuropathy resulting from chronic overuse. Mechanical symptoms may be due to posteromedial olecranon osteophytes, radiocapitellar pathology, or intra-articular loose bodies.

Examination

When examining a throwing athlete with elbow pain, it is important to also assess the shoulder and scapula, as injuries to these areas can lead to changes in throwing biomechanics and subsequent elbow injury. Dines et al. reported an association of pathologic glenohumeral internal rotation deficit (GIRD) with UCL insufficiency, as they found that baseball players with UCL injury had an average GIRD of 28.5°⁴⁰. The clinician should inspect both arms to detect asymmetry in forearm musculature or elbow carrying angle. Whereas the normal carrying angle is 11° to 13° of valgus, some authors have reported angles of >15° of valgus in throwing athletes^35,41.

Careful palpation of the UCL is performed with the elbow in 50° to 70° of flexion to displace the flexor-pronator mass anterior to the ligament⁴¹. Studies have shown that although UCL tenderness is 81% to 94% sensitive for ligamentous injury, it is not very specific (22%)^8,42. Paresthesia with gentle percussion of the ulnar nerve within the cubital tunnel together with tenderness along the course of the ulnar nerve may suggest the presence of neuropathy. In addition, the ulnar nerve should be specifically examined for subluxation at the medial humeral epicondyle.

Passive and active elbow motion in the throwing arm should be compared with that in the opposite extremity. It is not uncommon to observe an elbow extension deficit of 6.0° to 7.9°, and similar losses in flexion (4.0° to 5.5°) and supination (5°) have been reported in some studies^43,44. Although side-to-side differences in elbow range of motion may not always be indicative of pathologic conditions, subtle alterations such as a hard end point at terminal flexion may indicate that an osteophyte or a loose body is present.

The integrity of the UCL should be assessed with specific physical examination tests. The valgus stress test is performed with the arm stabilized against the examiner and the elbow flexed 30° to unlock the olecranon from its fossa. Valgus stress is applied at the elbow to detect widening at the ulnohumeral joint. Many patients will report medial elbow pain and instability with this maneuver. The “milking maneuver” is performed with the affected elbow flexed beyond 90°. The patient is asked to use the contralateral arm to stabilize the affected extremity while grasping the thumb of the affected extremity to generate valgus stress at the elbow. The test is considered positive if pain or instability is reproduced. O’Driscoll described the moving valgus stress test as a highly sensitive (100%) and specific test (75%) for UCL insufficiency⁴⁵. This test is performed by the examiner maintaining a valgus torque at the elbow in full flexion and quickly extending the elbow to generate a shear force at the UCL. This maneuver simulates the valgus force observed during the overhead throw. A positive test will result in pain from 70° to 120° of flexion.

Imaging

Routine diagnostic imaging begins with anteroposterior and lateral radiographs. A “thrower’s series” also includes internal and external oblique views, as well as an oblique axial view with the elbow in 110° of flexion to visualize posteromedial olecranon osteophytes (Fig. 5)³⁴. Wright et al. reviewed findings on routine elbow radiographs of Major League Baseball pitchers and noted a 10.7% prevalence of UCL ossification, a finding that has been recognized to be associated with chronic UCL injury⁴⁶. Athletes had a mean of seven abnormal radiographic findings, but no single finding was predictive of the length of time spent on the disabled list.

Fig. 5

Oblique axial elbow radiograph in 110° of elbow flexion demonstrating a posteromedial olecranon osteophyte in a twenty-nine-year-old professional baseball pitcher.

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Adjunctive stress radiographs have been used to evaluate throwing athletes for UCL insufficiency. Stress views of the injured and uninjured elbows in 25° to 30° of flexion are obtained as a valgus force is applied, and the difference in ulnohumeral widening is assessed. Rijke et al. investigated the utility of stress radiography in athletes and found that a side-to-side difference of >0.5 mm in the joint space was consistent with a UCL tear⁴⁷. Thompson et al. noted that 88% of throwing athletes who required UCL reconstruction demonstrated a side-to-side difference of ≥2 mm in the ulnohumeral joint space on stress radiographs⁴². Stress radiography has substantial shortcomings, as the variable ulnohumeral widening in normal elbows and the poor reproducibility of the technique (i.e., of the force applied and the degree of flexion) make side-to-side comparison unreliable⁴⁸.

Magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for the evaluation of UCL injury in the throwing athlete. High spatial resolution and exceptional soft-tissue contrast facilitates evaluation of the ligament and identification of associated intra-articular pathology. In the setting of acute injury, MRI will reveal irregularity in the ligament accompanied by increased signal intensity resulting from the fluid from both hemorrhage and edema⁴⁹. Non-contrast MRI has been reported to have a sensitivity of 57% to 79% and a specificity of 100% for diagnosing UCL tears^50,51, and the use of MR arthrography at some imaging centers has been reported to have greater sensitivity (Fig. 6)⁵².

Fig. 6

T2-weighted coronal magnetic resonance arthrogram in a twenty-two-year-old Division I college baseball pitcher with a full-thickness distal tear of the ulnar collateral ligament. Note the extravasation of arthrographic contrast material from the elbow joint (arrow).

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Computed tomography (CT) arthrography and ultrasonography can also be used to evaluate the UCL. Although CT has poor soft-tissue characterization and cannot provide accurate evaluation of the ligament, extravasation of the arthrography contrast medium beyond the medial aspect of the joint capsule may indicate a substantial UCL tear⁵⁰. Ultrasonography can also facilitate rapid and accurate evaluation of the UCL. A normal UCL appears hyperechoic between the medial humeral epicondyle and the ulna, whereas an abnormal UCL appears hypoechoic. The disrupted ligament fibers can be visualized, with anechoic fluid in the gap^53,54.

Nonoperative Management

Although the majority of available literature has focused on operative management of UCL tears, it is important to note that some UCL injuries can be successfully managed nonoperatively. Rettig and colleagues reviewed the outcomes following nonoperative management of thirty-one throwing athletes and found that 42% (thirteen of thirty-one) were able to return to their sport at or above the pre-injury level of play following adequate rehabilitation⁵⁵. Dodson et al. recently performed a retrospective review of ten National Football League (NFL) quarterbacks with UCL pathology, which was secondary to contact injury in seven of the ten⁵⁶. Nine of the ten players were successfully managed nonoperatively and returned to play in the NFL. The results in this cohort imply that acute, traumatic UCL tears may be more amenable to nonoperative management compared with chronic, attritional injuries.

Dines et al. recently investigated the utility of platelet-rich plasma in the nonoperative management of UCL injuries⁵⁷. Twenty-seven baseball players with partial UCL tears diagnosed with use of non-contrast MRI were treated with injections of platelet-rich plasma. At a mean of fourteen weeks of follow-up, 59% of players had an excellent outcome with return to their previous level of competition or higher.

Comparison of UCL Repair and Reconstruction

The initial operative approach to UCL injuries in throwing athletes involved repair of the native ligament. This early approach was supported by Barnes and Tullos, who noted that throwing athletes had better clinical outcomes after UCL repair than after nonoperative treatment⁵⁸. More recently, Savoie et al. described the outcome of repair of proximal or distal UCL tears in young amateur athletes (mean age, 17.2 years)⁵⁹. Ninety-seven percent were able to return to athletics at six months postoperatively, and 93% had good or excellent results at a mean of 59.2 months. Although UCL repair appears to be a viable option for young athletes with a tear located at the origin or insertion of the UCL, ligament reconstruction has become more common than repair in mature athletes with a chronic, attritional injury.

UCL Reconstruction: Evolution of Surgical Techniques and Clinical Outcomes

Jobe was the first to perform (in 1974) and to describe (in 1986) a standard technique for UCL reconstruction with use of autograft (palmaris, plantaris, or Achilles tendon) in a figure-of-eight graft configuration and submuscular ulnar nerve transposition (Fig. 7)². Ten (63%) of the sixteen patients who underwent UCL reconstruction returned to their previous level of competition after eleven to nineteen months, one (6%) returned to a lower level, and five (31%) retired. Conway et al. performed a follow-up study comparing clinical outcomes following UCL reconstruction with the original Jobe technique and following UCL repair³⁰. Sixty-eight percent of athletes who underwent UCL reconstruction were able to return to their previous level of competition, compared with only 50% of athletes who underwent UCL repair.

Fig. 7

The original figure-of-eight ulnar collateral ligament reconstruction and submuscular ulnar nerve transposition described by Jobe. (Reproduced from: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am. 1992;74:67-83.)

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Jobe also contrasted traumatic UCL disruption accompanying elbow dislocation and UCL injuries in throwing athletes, noting that the latter injuries “were associated with chronic overuse” secondary to repetitive overloading, with subsequent ligament attenuation and failure. Following Jobe’s observations regarding the quality of the injured ligament in throwing athletes as well as his operative success, UCL reconstruction has become the standard of care in throwing athletes.

Although the Jobe reconstruction technique defined a new approach toward treatment of UCL injury, several technical concerns persisted, including concerns involving the surgical approach, graft fixation, and graft tensioning. Jobe’s original approach involved transection and elevation of the common flexor origin², and thus resulted in morbidity associated with transection and repair of the flexor-pronator mass. In 1996, Smith and Altchek introduced a muscle-splitting approach that had several inherent advantages, most notably eliminating takedown of the common flexor origin to achieve direct visualization of the UCL⁶⁰. Several other modern technical alterations have resulted in excellent results in 82% to 95% of athletes (Table I). These alterations include the Jobe modification⁴², the American Sports Medicine Institute (ASMI) modification^61-64, the suture anchor method (hybrid technique)^65,66, the interference screw (DANE TJ) technique^67,68, and the docking technique^69-73 (Table II). The key aspects and clinical outcomes of these techniques are discussed below.

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TABLE I Summary of Clinical Outcomes*

Study	No. of Patients in Study	No. of UCL Reconstructions	No. (%) of Excellent Results on Conway Scale	No. (Type) of Complications	No. (Type) of Reoperations	Mean Age (Range) (yr)	No. of Patients by Sport	No. of Baseball Pitchers: Nonpitchers	No. of Baseball Players by Level of Play†	Mean Length of Follow-up (Range) (yr)	Mean Time to Return to Play (Range) (mo)
Jobe, 1986²	16	16	10/16 (63%)	5 (5 transient ulnar neuropathies)	2 (revision ulnar nerve procedures)	NR (20 to 31)	14 baseball, 2 javelin	13:1	5 MLB, 7 MiLB, 1 collegiate	4.3 (2 to 9.75)	NR (11 to 19)
Conway, 1992³⁰	71	56	38/56 (68%)	16 (15 ulnar neuropathies, 1 hematoma)	9 (revision ulnar nerve procedures)	23.7 (15 to 24)	52 baseball, 3 javelin, 1 tennis	45:7	20 MLB, 18 MiLB, 10 collegiate, 4 HS	6.3 (2 to 15)	12.5 (8 to 21)
Andrews, 1995⁶¹	72	12 (9 follow-up)	7/9 (78%)	1 (ulnar neuropathy)	0	NR	NR	NR	NR	NR	NR
Azar, 2000⁶²	91	78	53/67 (79%)	8 (4 graft site and 2 elbow superficial infections, 1 transient ulnar neuropathy, 1 posteromedial osteophyte)	2 (1 arthroscopic posteromedial osteophyte excision and 1 lysis of adhesions)	21.6 (15 to 39)	85 baseball, 3 football, 1 tennis, 1 wrestling, 1 fall-related	68:17	15 MLB, 22 MiLB, 41 collegiate, 7 HS	2.95 (1 to 6)	9.8 (NR)
Thompson, 2001⁴²	83	83 (33 follow-up)	27/33 (82%)	8 (4 transient ulnar and 2 median palmar cutaneous neuropathies, 1 flexor-pronator re-tear, 1 hematoma)	4 (1 flexor-pronator re-repair, 2 elbow and 1 posteromedial arthroscopic debridements)	24.3 (NR)	78 baseball, 2 javelin, 1 football, 1 platform diving, 1 softball	NR	54 professional, 18 collegiate, 6 HS, 5 recreational	3.1 (2 to 4)	13 (6 to 18)
Rohrbough, 2002⁶⁹	36	36	33/36 (92%)	2 (1 transient ulnar neuropathy, 1 wound hematoma)	1 (arthroscopic posteromedial debridement)	23 (15 to 57)	33 baseball, 1 lacrosse, 1 tennis, 1 golf	27:6	4 MLB, 5 MiLB, 12 collegiate, 6 HS	3.3 (2.1 to 5.3)	NR
Petty, 2004⁶³	31	31 (27 follow-up)	20/27 (74%)	3 (2 transient ulnar nerve neuropathies, 1 saphenous nerve neuropathy)	0	17.4 (15 to 19)	27 baseball	24:3	27 HS	2.92 (1.5 to 6.25)	11 (NR)
Paletta, 2006⁷²	25	25	23/25 (92%)	2 (1 transient ulnar neuropathy, 1 ulnar bridge stress fracture)	0	24.5 (19 to 27)	25 baseball	24:1	1 MLB, 19 MiLB, 5 collegiate	2.5 (2 to NR)	11.5 (10 to 16)
Dodson, 2006⁷⁰	100	100	90/100 (90%)	3 (2 ulnar neuropathies, 1 postoperative stiffness)	3 (2 primary ulnar nerve transpositions, 1 lysis of adhesions)	22.0 (16 to 43)	96 baseball, 2 football, 2 tennis	91:5	16 MLB or MiLB, 60 collegiate, 15 HS	3 (2 to 5)	NR
Koh, 2006⁷¹	20	20 (19 follow-up)	18/19 (95%)	1 ulnar neuropathy	1 (primary ulnar nerve transposition)	21.7 (17 to 25)	20 baseball	NR	13 MLB or MiLB, 7 collegiate	3.5 (0.5 to 5.6)	13.1 (NR)
Dines, 2007⁶⁸	22	22	19/22 (86%)	4 (2 postoperative stiffness, 1 posteromedial osteophyte with ulnar neuropathy, 1 ulnar neuropathy)	3 (2 lysis of adhesions, 1 posteromedial arthroscopic debridement)	20.1 (16 to 24)	20 baseball, 1 hockey, 1 football	16:4	1 MLB or MiLB, 16 collegiate, 3 HS	35.9 (19 to 55)	NR
Bowers, 2010⁷³	21	21	19/21 (90%)	0	0	20.0 (16 to 27)	21 baseball	NR	5 MLB or MiLB, 11 collegiate, 5 HS	28 (24 to 49)	NR
Hechtman, 2011⁶⁶	34	34	29/34 (85%)	1 (transient ulnar neuropathy)	0	18.7 (15 to 23)	34 baseball	29:5	20 collegiate, 14 HS	6.9 (4.2 to 8.7)	10 (7 to 13)
Cain, 2010⁶⁴	1281	1266 (743 follow-up)	617/743 (83%)	148 (16% minor, 4% major)	62 (53 posteromedial arthroscopic debridements, 9 revision UCL reconstructions)	21.5 (14 to 59)	1213 baseball, 15 javelin, 13 football, 9 softball, 7 tennis, 4 cheerleading, 2 wrestling, 2 soccer, 2 gymnastics, 1 pole-vaulting	1085:125	86 MLB, 300 MiLB, 583 collegiate, 240 HS or recreational	3.2 (2 to 10.8)	11.6 (3 to 72)
Total	1903	1800 (1219 follow-up)	1009/1219 (83%)	202/1219 (17%)	87/1219 (7%)

*UCL = ulnar collateral ligament, and NR = not reported.
†MLB = Major League Baseball, MiLB = Minor League Baseball, and HS = high school.

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TABLE I Summary of Clinical Outcomes*

Study	No. of Patients in Study	No. of UCL Reconstructions	No. (%) of Excellent Results on Conway Scale	No. (Type) of Complications	No. (Type) of Reoperations	Mean Age (Range) (yr)	No. of Patients by Sport	No. of Baseball Pitchers: Nonpitchers	No. of Baseball Players by Level of Play†	Mean Length of Follow-up (Range) (yr)	Mean Time to Return to Play (Range) (mo)
Jobe, 1986²	16	16	10/16 (63%)	5 (5 transient ulnar neuropathies)	2 (revision ulnar nerve procedures)	NR (20 to 31)	14 baseball, 2 javelin	13:1	5 MLB, 7 MiLB, 1 collegiate	4.3 (2 to 9.75)	NR (11 to 19)
Conway, 1992³⁰	71	56	38/56 (68%)	16 (15 ulnar neuropathies, 1 hematoma)	9 (revision ulnar nerve procedures)	23.7 (15 to 24)	52 baseball, 3 javelin, 1 tennis	45:7	20 MLB, 18 MiLB, 10 collegiate, 4 HS	6.3 (2 to 15)	12.5 (8 to 21)
Andrews, 1995⁶¹	72	12 (9 follow-up)	7/9 (78%)	1 (ulnar neuropathy)	0	NR	NR	NR	NR	NR	NR
Azar, 2000⁶²	91	78	53/67 (79%)	8 (4 graft site and 2 elbow superficial infections, 1 transient ulnar neuropathy, 1 posteromedial osteophyte)	2 (1 arthroscopic posteromedial osteophyte excision and 1 lysis of adhesions)	21.6 (15 to 39)	85 baseball, 3 football, 1 tennis, 1 wrestling, 1 fall-related	68:17	15 MLB, 22 MiLB, 41 collegiate, 7 HS	2.95 (1 to 6)	9.8 (NR)
Thompson, 2001⁴²	83	83 (33 follow-up)	27/33 (82%)	8 (4 transient ulnar and 2 median palmar cutaneous neuropathies, 1 flexor-pronator re-tear, 1 hematoma)	4 (1 flexor-pronator re-repair, 2 elbow and 1 posteromedial arthroscopic debridements)	24.3 (NR)	78 baseball, 2 javelin, 1 football, 1 platform diving, 1 softball	NR	54 professional, 18 collegiate, 6 HS, 5 recreational	3.1 (2 to 4)	13 (6 to 18)
Rohrbough, 2002⁶⁹	36	36	33/36 (92%)	2 (1 transient ulnar neuropathy, 1 wound hematoma)	1 (arthroscopic posteromedial debridement)	23 (15 to 57)	33 baseball, 1 lacrosse, 1 tennis, 1 golf	27:6	4 MLB, 5 MiLB, 12 collegiate, 6 HS	3.3 (2.1 to 5.3)	NR
Petty, 2004⁶³	31	31 (27 follow-up)	20/27 (74%)	3 (2 transient ulnar nerve neuropathies, 1 saphenous nerve neuropathy)	0	17.4 (15 to 19)	27 baseball	24:3	27 HS	2.92 (1.5 to 6.25)	11 (NR)
Paletta, 2006⁷²	25	25	23/25 (92%)	2 (1 transient ulnar neuropathy, 1 ulnar bridge stress fracture)	0	24.5 (19 to 27)	25 baseball	24:1	1 MLB, 19 MiLB, 5 collegiate	2.5 (2 to NR)	11.5 (10 to 16)
Dodson, 2006⁷⁰	100	100	90/100 (90%)	3 (2 ulnar neuropathies, 1 postoperative stiffness)	3 (2 primary ulnar nerve transpositions, 1 lysis of adhesions)	22.0 (16 to 43)	96 baseball, 2 football, 2 tennis	91:5	16 MLB or MiLB, 60 collegiate, 15 HS	3 (2 to 5)	NR
Koh, 2006⁷¹	20	20 (19 follow-up)	18/19 (95%)	1 ulnar neuropathy	1 (primary ulnar nerve transposition)	21.7 (17 to 25)	20 baseball	NR	13 MLB or MiLB, 7 collegiate	3.5 (0.5 to 5.6)	13.1 (NR)
Dines, 2007⁶⁸	22	22	19/22 (86%)	4 (2 postoperative stiffness, 1 posteromedial osteophyte with ulnar neuropathy, 1 ulnar neuropathy)	3 (2 lysis of adhesions, 1 posteromedial arthroscopic debridement)	20.1 (16 to 24)	20 baseball, 1 hockey, 1 football	16:4	1 MLB or MiLB, 16 collegiate, 3 HS	35.9 (19 to 55)	NR
Bowers, 2010⁷³	21	21	19/21 (90%)	0	0	20.0 (16 to 27)	21 baseball	NR	5 MLB or MiLB, 11 collegiate, 5 HS	28 (24 to 49)	NR
Hechtman, 2011⁶⁶	34	34	29/34 (85%)	1 (transient ulnar neuropathy)	0	18.7 (15 to 23)	34 baseball	29:5	20 collegiate, 14 HS	6.9 (4.2 to 8.7)	10 (7 to 13)
Cain, 2010⁶⁴	1281	1266 (743 follow-up)	617/743 (83%)	148 (16% minor, 4% major)	62 (53 posteromedial arthroscopic debridements, 9 revision UCL reconstructions)	21.5 (14 to 59)	1213 baseball, 15 javelin, 13 football, 9 softball, 7 tennis, 4 cheerleading, 2 wrestling, 2 soccer, 2 gymnastics, 1 pole-vaulting	1085:125	86 MLB, 300 MiLB, 583 collegiate, 240 HS or recreational	3.2 (2 to 10.8)	11.6 (3 to 72)
Total	1903	1800 (1219 follow-up)	1009/1219 (83%)	202/1219 (17%)	87/1219 (7%)

*UCL = ulnar collateral ligament, and NR = not reported.
†MLB = Major League Baseball, MiLB = Minor League Baseball, and HS = high school.

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TABLE II Summary of Techniques*

Study	Technique	Flexor-Pronator Mass Approach	Fixation (No. of Tunnels)		Graft Choice (No.)	Ulnar Nerve Transposition
Humeral	Ulnar	Obligatory	Technique
Jobe, 1986²	Figure-of-8	Detachment	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (12), plantaris (3), Achilles (1)	Yes	Submuscular in 16/16 (100%)
Conway, 1992³⁰	Figure-of-8	Detachment	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (45), plantaris (7), Achilles (3), toe extensor (1)	Yes	Submuscular in 55/56 (98%)
Andrews, 1995⁶¹	Figure-of-8	Elevation	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (NR), toe extensor (NR)	Yes	Subcutaneous in 9/9 (100%)
Azar, 2000⁶²	Figure-of-8	Elevation	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (63), toe extensor (9), plantaris (6)	Yes	Subcutaneous in 67/67 (100%)
Thompson, 2001⁴²	Figure-of-8	Muscle split	Distal 4.5-mm (1), proximal 3.5-mm (2)	3.5-mm (2)	Palmaris (80), plantaris (2), toe extensor (1)	No	Not performed
Rohrbough, 2002⁶⁹	Docking	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (34), gracilis (1), toe extensor (1)	No	Subcutaneous
Petty, 2004⁶³	Figure-of-8	Elevation	Palmaris 3.6-mm (3), gracilis 4.0-mm (3)	Palmaris 3.6-mm (2), gracilis 4.0-mm (2)	Palmaris (21), gracilis (6)	Yes	Subcutaneous
Paletta, 2006⁷²	Docking	Muscle split	Distal 4 or 5-mm (1), proximal 2.0-mm (2)	3.0-mm (2)	Palmaris (23), gracilis (2)	No	Subcutaneous
Dodson, 2006⁷⁰	Docking	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (70), gracilis (30)	No	Subcutaneous
Koh, 2006⁷¹	Modified docking (3 or 4-strand graft)	Muscle split	Distal 4.0-mm (1), proximal drill hole (2, size NR)	4.0-mm (2)	Palmaris (19), gracilis (1)	No	Subcutaneous
Dines, 2007⁶⁸	DANE TJ	Muscle split	Distal 4.5-mm (1), proximal 2.7-mm (2)	1 biotenodesis screw (size NR)	Palmaris (12), gracilis (10)	No	Subcutaneous
Bowers, 2010⁷³	Modified docking (3-strand graft)	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (NR), gracilis (NR)	No	Subcutaneous
Hechtman, 2011⁶⁶	Hybrid	Muscle split	2 suture anchors (sizes NR)	3.2-mm (2)	Palmaris (29), plantaris (3), Achilles (2)	No	Subcutaneous
Cain, 2010⁶⁴	Figure-of-8	Elevation	Palmaris 3.6-mm (3), gracilis 4.0-mm (3)	Palmaris 3.6-mm (2), gracilis 4.0-mm (2)	Palmaris (935), gracilis (294), toe extensor (30), plantaris (23), patellar tendon (1)	Yes	Subcutaneous

*NR = not reported.

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TABLE II Summary of Techniques*

Study	Technique	Flexor-Pronator Mass Approach	Fixation (No. of Tunnels)		Graft Choice (No.)	Ulnar Nerve Transposition
Humeral	Ulnar	Obligatory	Technique
Jobe, 1986²	Figure-of-8	Detachment	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (12), plantaris (3), Achilles (1)	Yes	Submuscular in 16/16 (100%)
Conway, 1992³⁰	Figure-of-8	Detachment	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (45), plantaris (7), Achilles (3), toe extensor (1)	Yes	Submuscular in 55/56 (98%)
Andrews, 1995⁶¹	Figure-of-8	Elevation	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (NR), toe extensor (NR)	Yes	Subcutaneous in 9/9 (100%)
Azar, 2000⁶²	Figure-of-8	Elevation	Distal 3.2-mm (1), proximal 3.2-mm (2)	3.2-mm (2)	Palmaris (63), toe extensor (9), plantaris (6)	Yes	Subcutaneous in 67/67 (100%)
Thompson, 2001⁴²	Figure-of-8	Muscle split	Distal 4.5-mm (1), proximal 3.5-mm (2)	3.5-mm (2)	Palmaris (80), plantaris (2), toe extensor (1)	No	Not performed
Rohrbough, 2002⁶⁹	Docking	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (34), gracilis (1), toe extensor (1)	No	Subcutaneous
Petty, 2004⁶³	Figure-of-8	Elevation	Palmaris 3.6-mm (3), gracilis 4.0-mm (3)	Palmaris 3.6-mm (2), gracilis 4.0-mm (2)	Palmaris (21), gracilis (6)	Yes	Subcutaneous
Paletta, 2006⁷²	Docking	Muscle split	Distal 4 or 5-mm (1), proximal 2.0-mm (2)	3.0-mm (2)	Palmaris (23), gracilis (2)	No	Subcutaneous
Dodson, 2006⁷⁰	Docking	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (70), gracilis (30)	No	Subcutaneous
Koh, 2006⁷¹	Modified docking (3 or 4-strand graft)	Muscle split	Distal 4.0-mm (1), proximal drill hole (2, size NR)	4.0-mm (2)	Palmaris (19), gracilis (1)	No	Subcutaneous
Dines, 2007⁶⁸	DANE TJ	Muscle split	Distal 4.5-mm (1), proximal 2.7-mm (2)	1 biotenodesis screw (size NR)	Palmaris (12), gracilis (10)	No	Subcutaneous
Bowers, 2010⁷³	Modified docking (3-strand graft)	Muscle split	Distal 4.0-mm (1), proximal 1.5-mm (2)	3.0-mm (2)	Palmaris (NR), gracilis (NR)	No	Subcutaneous
Hechtman, 2011⁶⁶	Hybrid	Muscle split	2 suture anchors (sizes NR)	3.2-mm (2)	Palmaris (29), plantaris (3), Achilles (2)	No	Subcutaneous
Cain, 2010⁶⁴	Figure-of-8	Elevation	Palmaris 3.6-mm (3), gracilis 4.0-mm (3)	Palmaris 3.6-mm (2), gracilis 4.0-mm (2)	Palmaris (935), gracilis (294), toe extensor (30), plantaris (23), patellar tendon (1)	Yes	Subcutaneous

*NR = not reported.

Jobe Modification

Jobe modified his original surgical approach to make use of the inherent advantages of the muscle-splitting technique but continued to use the figure-of-eight graft configuration⁴². He performed the reconstruction through a flexor-pronator muscle-splitting approach without subcutaneous ulnar nerve transposition. The clinical results of this modified technique in eighty-three athletes were reported in 2001; 82% of all throwing athletes and 93% of throwers without prior elbow surgery returned to play at a mean of thirteen months⁴². There were few complications, which included four reoperations in three patients and a 5% prevalence of transient ulnar nerve symptoms.

ASMI Modification

The technique described by Andrews in 1995 utilized a posterior approach between the two heads of the flexor carpi ulnaris, with elevation of the flexor-pronator mass without takedown (Fig. 8)⁶¹. An ulnar nerve transposition was performed in all cases. The 1995 report describing his initial experience with UCL reconstruction included an evaluation of all consecutive procedures performed between 1986 and 1990.

Fig. 8

ASMI modification. The curved arrow demonstrates elevation of the flexor-pronator mass attached to the medial epicondyle (dashed arrow). Note the course of the ulnar nerve as it travels between the ulnar and humeral heads of the flexor carpi ulnaris (solid arrow).

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Azar et al. provided the first report comparing UCL reconstruction using the ASMI modification and UCL repair⁶². This study involving ninety-one baseball players indicated the outcome of UCL reconstruction to be more reliable, with 79% of these patients returning to their pre-injury level of play compared with 63% of patients treated with UCL repair. In the most comprehensive study to date, Cain and colleagues evaluated the clinical outcome of the ASMI modification in 1281 throwing athletes⁶⁴. Overall, 83% of the athletes returned to their pre-injury level of competition or higher at a mean of thirty-eight months. Among the baseball players, return to the same or a higher level of play occurred in 75.5% of Major League, 73% of Minor League, 87.5% of collegiate, and 83% of high school players. Complications occurred in 20% of the patients; however, only 4% were classified as major and the remainder were classified as minor. Transient ulnar nerve symptoms were the most common type of complication.

Docking Technique

Altchek and colleagues have reported successful outcomes with use of the docking technique, which likewise incorporates the flexor-pronator muscle-splitting approach but reconstructs the UCL with a triangular graft configuration through a single Y-shaped humeral tunnel⁶⁹ (Fig. 9). The longitudinal distal portion of this tunnel is created with use of a 4-mm burr, and the two small proximal exit holes are created with use of a 1.5-mm drill. The ulnar tunnel configuration is similar to that described by Jobe.

Fig. 9

Docking technique. Note the two graft limbs securely “docked” within the humeral tunnel.

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A systematic review by Vitale et al. has demonstrated that the docking technique performed with a flexor-pronator muscle-splitting approach and with decreased handling of the ulnar nerve has improved outcomes and decreased the complication rate compared with other techniques⁷⁴. In the earliest review of the outcome of the docking technique, 92% of patients (thirty-three of thirty-six) returned to their pre-injury level of play for at least one year, and all twenty-two professional or collegiate athletes returned to or exceeded their prior level of competition⁶⁹. A more recent follow-up study has confirmed these results, with 90% of patients (ninety of 100) returning to play and only three patients (3%) experiencing postoperative complications⁷⁰.

Numerous modifications of the docking technique have been proposed and shown to have favorable results^71-73. These modifications focus largely on three and four-strand graft reconstructions, and 90% to 95% of athletes were able to return to the same or a higher level of play^71-73.

DANE TJ Technique

The DANE TJ technique for UCL reconstruction was first described by Conway in 2006 (Fig. 10)⁷⁵. This approach represents a hybrid of two fixation strategies described by David Altchek and Neal ElAttrache (DANE) for Tommy John (TJ) surgery. This technique was developed to improve fixation and avoid complications at the humeral and ulnar bone tunnel sites by taking advantage of the excellent results of the docking technique and the favorable biomechanical characteristics of interference screw fixation^67,70.

Fig. 10

DANE TJ technique demonstrating interference screw fixation on the ulnar side and the two graft limbs securely “docked” within the humeral tunnel. (Reproduced, with permission from Elsevier, from: Shah RP, Lindsey DP, Sungar GW, McAdams TR. An analysis of four ulnar collateral ligament reconstruction procedures with cyclic valgus loading. J Shoulder Elbow Surg. 2009 Jan-Feb;18[1]:58-63. Copyright [2009]. http://www.sciencedirect.com/science/journal/10582746.)

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Dines et al. conducted the first and to our knowledge only clinical investigation of this technique to date⁶⁸. Nineteen (86%) of the twenty-two athletes studied returned to the same or a higher level of play for at least one season. Postoperative complications occurred in four patients, resulting in three reoperations.

Hybrid Technique

Humeral graft fixation with suture anchors has also been utilized to simplify UCL reconstruction and potentially reduce morbidity associated with humeral tunnel drilling. In previous biomechanical studies, Hechtman and colleagues found that their humeral suture anchor technique resulted in fixation strength similar to that of osseous tunnels⁶⁵. Despite the apparent biomechanical success of this technique, other authors initially reported a higher clinical failure rate when using suture anchor fixation in small case series⁷⁶. More recently, a larger clinical study was performed to determine the utility of suture anchor fixation. Eighty-five percent of athletes returned to the same or a higher level of play, and only one (3%) reported transient ulnar nerve paresthesias⁶⁶.

Revision UCL Reconstruction

Although excellent results can be expected in most patients who undergo primary UCL reconstruction, re-tears of the ligament have been reported. Dines and Jobe provided a clinical report on the postoperative outcome of revision UCL reconstruction in a series of fifteen baseball players⁷⁷. Only five patients (33%) were able to return to their previous level of competition for at least one year. As expected with any revision procedure, the complication rate was high (40%), with two of the complications being major (re-tear of the ligament and loss of motion requiring lysis of adhesions). Interestingly, the rate of ulnar nerve complications (6%) was similar to that observed for primary UCL reconstruction.

Outlook

Overhead throwing athletes place substantial demands on the UCL, and repetitive overuse can result in chronic attenuation of the ligament. Prior to modern surgical reconstruction, this injury in athletes was considered career-ending. However, the role of ligamentous reconstruction in the throwing athlete has now been well described and widely accepted. With the evolution of UCL reconstruction techniques, including minimal dissection of the flexor-pronator mass and decreased handling of the ulnar nerve, successful return to athletic competition is now possible in most overhead athletes who undergo UCL reconstruction.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

reconstructive surgical procedures ; sports medicine ; ulnar collateral ligament of elbow joint ; athlete ; repair lateral collateral ligament, elbow, with local tissue

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Kristofer J. Jones, Daryl C. Osbahr, Mark A. Schrumpf, Joshua S. Dines, David W. Altchek; Ulnar Collateral Ligament Reconstruction in Throwing Athletes: A Review of Current ConceptsAAOS Exhibit Selection. The Journal of Bone & Joint Surgery. 2012 Apr;94(8):e49 1-12.

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