Review Question - QID 219859

This 29-year-old male professional pitcher sustained a medial ulnar collateral ligament (mUCL) rupture. The technique most appropriate to allow him to return to sport while minimizing his complication rates would be mUCL autograft reconstruction utilizing the docking technique (Answer 2).

Medial ulnar collateral ligament disruptions are common injuries among overhead athletes, particularly pitchers. While nonoperative treatment in the form of rest and physical therapy is often the most appropriate initial treatment, professional pitchers often undergo immediate reconstruction to accelerate their return to sport. Several techniques have been described, with the most notable techniques being the flexor-pronator tenotomy/detachment utilizing a figure of eight ligament reconstruction ("Jobe"), muscle splitting approach with the figure of eight reconstruction ("modified Jobe"), and muscle splitting docking technique. The lattermost, which involves creating a bone tunnel in the sublime tubercle and a singular socket made in the medial epicondyle, is advantageous as it allows for less ulnar nerve manipulation (therefore leading to few ulnar nerve injuries/neuropraxia), better graft tensioning, and an overall decrease in complications. Lastly, the utilization of autograft (typically palmaris longus) has become the standard for reconstruction, secondary to reduced revision rates (autograft: 1.6%, allograft: 2.6%).

Gehrman and Grandizio review the anatomy/biomechanics, diagnosis, and treatment of mUCL injuries. The authors note that while the figure of eight and docking techniques both are adequate in reconstructing the mUCL, the docking technique has shown an improved return to play rates (greater than 90%) compared to the figure of eight technique (80-85%), as well as fewer instances of ulnar nerve complication. The authors conclude their preferred technique is the docking technique, as it allows for better tensioning.

Clain et al. performed a systematic review of seventeen articles examining the incidence of postoperative ulnar nerve complications following mUCL reconstruction. The authors noted detachment of the flexor-pronator mass caused the highest rates of nerve complications at 21.9% (versus splitting at 3.9%), while the figure of eight techniques (Jobe: 9%; modified Jobe: 16.9%) was significantly higher than the docking technique (3.3%). Furthermore, they note the inclusion of an ulnar nerve transposition also increased injury rates (16.1%). The authors conclude the highest rates of neuropathy were with detachment of the flexor-pronator mass, utilization of the modified Jobe technique, and the inclusion of the ulnar nerve transposition.

Carr et al. provide a review of mUCL injuries, stating that strains and partial rupture should undergo a trial of nonoperative management before consideration of operative intervention. For those with complete ruptures, mUCL reconstruction remains the gold standard. The authors note that return-to-play rates are excellent (> 80% for both) for both procedures, but the length of time is often variable, ranging from 12 to 18 months.

Figure A represents a coronal T2-weighted image illustrating a mUCL rupture from its humeral origin.

Incorrect Answers:
Answer 1: The figure of eight technique has demonstrated higher rates of complications and has largely been supplanted by the docking technique. Moreover, the utilization of allograft has also shown increased revision rates.
Answer 3: While the docking technique does confer reduced complication rates compared to figure of eight, allograft utilization would not be the ideal graft to employ
Answers 4 & 5: Concomitant ulnar nerve decompression is not indicated in this patient, as he does not exhibit any ulnar nerve symptoms.