Elbow Collateral Ligament Insufficiency Treatment & Management

Surgical reconstruction is indicated in the following patients:

• Overhead-throwing athletes with acute complete medial collateral ligament (MCL) ruptures or chronic instability for more than 6 months, with medial elbow pain that prevents throwing and is refractory to conservative treatment
• Patients in whom preoperative standard noncontrast magnetic resonance imaging (MRI) demonstrates medial ulnar collateral ligament (UCL) injury
• Patients with clinically apparent medial UCL (MUCL) insufficiency
• Unstable reduction after traumatic fracture dislocation of the elbow joint

Relative contraindications for surgical treatment include the following:

• Medical contraindication for surgery
• Patient noncompliance
• An elbow joint that is stable after closed reduction through a functional (30-130°) range of motion (ROM), with minimally displaced fractures following fracture dislocations of the elbow

Most symptomatic conditions of the overhead athlete can initially be treated conservatively. Any thrower who is experiencing medial elbow pain should refrain from pitching until he or she has had a thorough evaluation; a past history of medial elbow pain is a risk factor for fracture of the medial epicondyle. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help relieve the pain and control the inflammatory reaction.

There is no evidence that the results of surgical repair of the ligaments are any better than those of nonsurgical treatment in patients with medial or both lateral and medial laxity of the elbow following nonfracture dislocations.

Platelet-rich plasma

Several studies have shown that platelet-rich plasma (PRP) injection can be a valuable component of nonoperative management in throwing athletes with elbow collateral ligament injuries.

Dines et al retrospectively evaluated the effect of PRP injections in 44 baseball players with partial UCL tears (mean age, 17.3 years; range, 16-28), of whom 16 had a single injection, six had two, and 22 had three. ^[29] At follow-up (mean, 11 months after injection), 15 of the 44 patients (34%) had an excellent outcome, 17 had a good outcome, two had a fair outcome, and 10 had a poor outcome. Mean time from injection to return to throwing was 5 weeks; mean time to return to competition was 12 weeks (range, 5-24 weeks). There were no injection-related complications.

Deal et al reported a case series of 25 throwing athletes with partial MUCL tears who were treated with two leukocyte-rich PRP injections, bracing, physical therapy, and a structured return-to-throwing protocol. ^[30]  Of the 25 patients, 23 were diagnosed with primary grade 2 MUCL injuries, and 22 of the 23 (96%) demonstrated stability of the MUCL after treatment and returned to play at the same or higher level of competition without further intervention. Two of the 25 had undergone prior surgery; they remained unstable and symptomatic after this regimen, did not have complete reconstitution of the ligament on subsequent MRI, and required surgical reconstruction of the MUCL.

Postreduction assessment of stability

After reduction of a dislocated elbow, the elbow will generally be stable in 90º or more of flexion. If instability occurs in 30º of flexion, the forearm should be placed in maximum pronation, which maximizes the stress on the MCL and reduces the posterolateral subluxation. If there is increased stability in pronation, the elbow should be placed in a cast brace with the elbow in pronation.

In cases where conservative treatment is unsuccessful, surgical intervention is indicated. ^{[3, 5, 6, 8, 9, 19, 20, 21, 22, 23, 31]}

Choice of operative approach

Direct MCL repair is commonly used in acute ligamentous avulsions from the humeral origin (most commonly) or the sublime tubercle. Graft reconstruction is commonly performed with autologous grafts (palmaris longus, plantaris, 3.5-mm medial strip of Achilles, or hamstrings) and occasionally with allografts. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, is similar in strength to the anterior bundle of the MCL (AMCL): 357 N vs average failure load of 260 N.

No difference has been observed between single-strand and double-strand repair techniques. (See the images below.)

MCL reconstruction is carried out by several means. The strengths achievable with four commonly practiced methods relate to the strength of an intact ligament as follows:

• Intact ligaments are three times stronger than docking reconstructions
• Docking reconstructions and Endobutton reconstructions are equally strong
• Endobutton reconstructions are stronger than interference screw reconstructions
• Interference screw reconstructions are stronger than figure-eight reconstructions

However, the use of bioabsorbable interference screw fixation has resulted in less valgus angle widening in response to early cyclic valgus load than the use of the docking technique. Hence, the optimal fixation method for a single-strand MCL reconstruction may require improved interference screws or a modified Endobutton procedure.

Lateral collateral ligament (LCL) repair and reconstruction for posterolateral rotatory instability of the elbow using a tendon graft seem to provide better results than direct ligament repair, and the results do not seem to deteriorate with time. In primary cases such as traumatic fracture dislocation of the elbow, it usually is not necessary to employ tendon grafts or to perform ligament augmentations. On the grounds that the anconeus is a potential posterolateral stabilizer of the elbow in posterolateral elbow instability, an anconeus-sparing minimally invasive approach has been suggetsed as a means of restoring posterolateral stability. ^[32]

In posteromedial olecranon impingement, valgus angulation and varus-valgus laxity increase proportionately with the amount of olecranon resection. At 90° of elbow flexion and 3 N-m of applied torque, olecranon resections of 0, 4, and 8 mm produced varus-valgus laxity of 14°, 15°, and 18°, respectively. Hence, resections of the medial part of the olecranon for the treatment of posteromedial olecranon impingement in the throwing athlete should be limited to the osteophytes alone.

In general terms, surgery is indicated if one is unable to get stability of the LCL even with a hinged brace. If there is avulsion from the bone (usually off the humerus), repair is indicated.

If repair is impossible, reconstruction is indicated.

Preparation for surgery

Isometric fibers do not exist within the AMCL; however, nearly isometric areas are located on the lateral aspect of the attachment site of the AMCL on the medial epicondyle, near the anatomic axis of rotation. Hence, it has been postulated that these nearly isometric areas would be the ideal location for graft attachment during reconstruction of the AMCL. ^[33]

A tear of the deep layer of the UCL can result in symptomatic instability that is difficult to diagnose with conventional preoperative testing. These throwing-athletic patients present with persistent medial elbow pain, tenderness over the anterior bundle of the UCL, and pain with valgus stressing of the elbow.

MRI may be normal, and a computed tomography (CT) arthrogram may be negative for extracapsular contrast extravasation. A consistent finding in these patients could be a leak of contrast around the edge of the humerus or ulna, though the contrast is contained within the joint. On open medial elbow surgery, the UCL appears intact externally; but when the anterior bundle is incised, there would be a detachment of the undersurface of the ligament at the ulna or the humerus.

Operative details

UCL reconstruction is the current gold standard for managing UCL insufficiency; reconstruction techniques that have been described include the original and modified Jobe techniques as well as various docking techniques. ^[34]

The docking technique for UCL reconstruction involves a muscle-splitting approach to the ligament that spares the flexor origin. It also involves the use of one hole in the medial epicondyle rather than three, avoids the need to transpose the ulnar nerve, and simplifies the method of graft-tensioning prior to fixation. ^[6]

A systematic review and meta-analysis (four studies; 92 elbows) by Erickson et al suggested that UCL repair could be an acceptable alternative to UCL reconstruction for treatment of UCL tears. ^[35] In this study, repair, as compared with reconstruction, yielded similar return-to-sport rates and clinical outcomes and a shorter time to return to sport. Khalil et al described an approach to primary repair of proximal ulnar collateral ligament ruptures in pediatric overhead athletes. ^[36]  

In traumatic fracture dislocation of the elbow, detachment of the LCL complex from the humerus is repaired with nonabsorbable sutures placed either through drill-holes in the bone or with suture anchors. The most important suture is the stitch placed in the center of rotation of the elbow laterally, located at the center of the capitellar circumference in the lateral condyle. Midsubstance tears of the LCL are occasionally seen and are repaired with No. 1 or 2 nonabsorbable sutures.

A split anconeus fascia transfer to reconstruct the LCL complex comprises a strip of anconeus fascia detached from its origin and split in line with its fibers down to its ulnar insertion. The superior segment is passed under the anular ligament (AL) to reconstruct the proper radial collateral ligament (RCL), while the inferior segment is used to reconstruct the lateral UCL (LUCL). A docking technique is used to secure the fascia to the isometric point on the lateral epicondyle. (See the images below.)

Thus, a local graft can be used for anatomic reconstruction without the associated morbidity of tendon harvest, especially when instability arises during surgery.

Before definitive closure, the elbow is examined for stability. The goal is concentric reduction with no observed posterior or posterolateral subluxation or dislocation through an arc of flexion.

Postoperative care includes the following:

• Lateral-side injuries - Treat/immobilize in pronation
• Medial-side injuries - Treat/immobilize in supination
• Combined injuries - Treat/immobilize in neutral rotation

Potential complications of surgical treatment include the following:

• Detachment of the origin of the flexor-pronator muscle group
• Requirement for transposition of the ulnar nerve owing to ulnar nerve symptoms
• Fracture of the medial epicondyle secondary to multiple drill holes
• Inadequate graft-tensioning during fixation of the graft
• Transient radial-nerve palsy after intra-articular injection of local anesthetic
• Decreased ROM with a variable degree of flexion contracture and loss of flexion

After MCL reconstruction, which is secured in supination, immobilize the elbow for 1 week, then start active ROM (AROM) for the shoulder, elbow, and wrist in a supination brace. After 6 weeks, begin resistance strengthening. Valgus stress should be avoided for 3 months.