Published 4/23/2025
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Bradley Lezak, MD, MPH
Editor's note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.
The incidence and subsequent surgery for medial ulnar collateral ligament (MUCL) injuries have increased dramatically over the past 10 years. MUCL injury often is experienced by overhead throwing athletes, typically requiring 12 to 18 months of rehabilitation before return to sport.
MUCL reconstruction, also known as Tommy John surgery, has an interesting history that reflects the evolution of sports medicine and surgical techniques. Frank W. Jobe, MD, pioneered the first UCL reconstruction in 1974 on Los Angeles Dodgers pitcher Tommy John using a figure-of-eight graft figuration.
Several techniques have been described since that time, including the modified Jobe technique and docking technique, as well as newer repair and reconstruction techniques using an internal brace. In each of these surgical techniques, however, the graft does not anatomically restore the MUCL.
Fig. 1 Sutures are placed through the native (torn) medial ulnar collateral ligament.
Fig. 2 A 4 mm hole is drilled into the origin of the medial ulnar collateral ligament at the medial epicondyle, followed by two 2 mm holes proximal but connected to the 4 mm hole.
Fig. 3 The bone-tendon-bone tightrope is placed through the medial epicondyle drill holes, and the autograft and suture tape are reduced into the humeral socket.
Christopher L. Camp, MD, from Mayo Clinic, has developed an anatomic technique, which allows for a more anatomic restoration, increased biomechanical strength compared to the docking technique, concomitant repair of the native MUCL under the graft, and addition of suture-tape augmentation for additional biomechanical strength. A recent video from Dr. Camp and colleagues, published in the AAOS OVT Plus collection, describes the technique and early results.
The presenters begin the video by demonstrating their technique for harvesting the palmaris longus tendon using a 5 mm tendon stripper (Fig. 1). Next, a second incision is made over the medial epicondyle to expose the UCL using a 6 cm incision, starting 2 cm proximal to the medial epicondyle and extending 4 cm distal to the medial epicondyle. The sublime tubercle is palpated, and a flexor pronator split approach is used to gain access to the UCL. Given that the patient had a proximal UCL tear, the ligament is elevated through the proximal tear so the surgical team can identify the joint line. Sutures are placed into the torn native ligament with a running Krackow stitch for later repair.
Next, a 4 mm hole is drilled into the origin of the native UCL at the medial epicondyle to a depth of 15 mm. The C-shaped drill guide is then used to drill two additional 2 mm sockets proximally. Shuttling sutures are passed through these in a bidirectional fashion (Fig. 2). One passing suture is used to pass the native ligament, and the other is tagged and laid aside. This step is repeated through the second 2 mm socket. The suture button suspensory device is then placed through the medial epicondyle drill holes, which will subsequently be used to pass the autograft and suture-tape augmentation into the humeral socket. These are passed and reduced with the use of adjustable loop fixation, which can be re-tensioned at the end of the case (Fig. 3).
At this point, attention turns to the ulna. The proximal suture anchors are placed on both sides of the sublime tubercle—native insertion of the UCL—just distal to the joint line on the anterior and posterior edge of the native ligament. The distal end of the graft is whip stitched and secured to the sublime tubercle with the use of suture anchors.
The suture tapes are then loaded into an additional suture anchor and placed distally into the sublime tubercle ridge. This creates the “anatomic reconstruction construct.” The anchor is fixed with the elbow at 45 degrees of flexion and a varus load. Final fixation includes re-tensioning of the native ligament sutures and tightrope across the humeral bone bridge proximally. Lastly, sutures are passed between the native ligament, autograft, and suture tapes to bring these together as a single structure. The fascia is closed over the top.
The video includes the “Accelerated MUCL Rehab Protocol” recommended by the video authors. The patient is placed in a hinged elbow brace locked with no range of motion (ROM) for the first 2 weeks, then subsequently fully unlocked with progressive ROM at week 2 with a goal of full ROM by week 6. Gentle strengthening is initiated at weeks 6 to 12. An interval throwing program is initiated at month 3, with a goal of return to competitive pitching at 9 months.
This OVT Plus video is a thorough review of one of the latest techniques for UCL reconstruction. The results of this technique are still under investigation; however, in a cohort of 26 professional and amateur overhead throwing athletes undergoing this procedure for MUCL instability, more than 90 percent returned to play at the same level at a mean time of 9.9 months. The preliminary results demonstrate that this is a viable treatment option with potentially expedited return to sport.
Bradley Lezak, MD, MPH, is an orthopaedic surgery resident at NYU Langone Orthopedics and a member of the AAOS Now Editorial Board.
Video details
Title: Anatomic Medial Ulnar Collateral Ligament Reconstruction with Internal Brace Augmentation in Throwing Athletes
Authors: Kevin Jurgensmeier, MD; Alexander M. Boos, BA; Christopher L. Camp, MD; Joshua S. Dines, MD, FAAOS
Published: Jan. 31, 2024
Time: 10:12
Tags: Sports Medicine, Ligamentous Injuries, Athletes, Reconstruction
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