MUCL REPAIR - AOSSM · • Jobe reconstruction (“Tommy John” surgery) is standard of care •...

Tulane Orthopaedic Surgery

Felix H. Savoie III, MDRay J. Haddad Professor & Chairman Department of Orthopaedic Surgery

Tulane UniversityNew Orleans, LA

MUCL REPAIR

MUCL INJURY EPIDEMIC• Frequency increasing despite major efforts

at injury prevention • Occurring in younger athletes• Do we treat these young athletes like

professionals?


MUCL ETIOLOGY• Acute: pop with one throw• Fatigue, decreased arm / trunk angle,

“opening up” too soon: classic is medial apophyseal avulsion

• Attritional / Chronic• Core / hip weakness• Slow loosening


MUCL EXAM• Inspect for

swelling • Palpate for

tenderness• Valgus stress test

in pron. and sup. • Moving valgus

stress test• VEO test


MUCL MANAGEMENT• Stop playing • Play with pain• Rest, brace, and rehab and let it heal• PRP injections• Repair • Reconstruction

– Autograft vs. Allograft


MUCL MANAGEMENT• Stop playing

– This ligament only comes into play in athletics– There are NO long term consequences of not

fixing it– “But Doc, my son / daughter loves baseball

and is the best player ever in his / her league! He / she has a future in this sport!”


MUCL MANAGEMENT• Play with pain

– Usually highest velocity is around 83 mph– Will NOT lead to arthritis– Will get worse? Maybe pain gets worse, but

instability doesn’t


MUCL MANAGEMENT• Rest, brace, and rehab and let it heal• Initial reports showed about 40% (Rettig, et

al.) effective but in young pts may be 75%• Current concept is bracing and rehab to

strengthen and balance the rest of the body while protecting the ligament

• Can play with brace if pain-free• Usually a 3 - 6 week program


MUCL MANAGEMENT• PRP injections

– Podesta (Yokum): 88% RTP in a series of 34 partial MUCL tears that failed other treatment, our results similar

– Our protocol is a series of 2 injections, brace, and PT program with repeat MRI in 4 weeks: insurance approval problematic and kits cost about $325 each


MUCL: SURGERY• Jobe reconstruction (“Tommy John”

surgery) is standard of care• May be only surgery that parents request• In the early series (all professionals), repair

was not effective • Currently we have better diagnostic

modalities, better anchors and sutures for repair. It also allows younger athletes to RTP in half the time.


INDICATIONS• Failure of non-operative treatment• Desire to continue to play • Ability and means to properly rehabilitate

after the surgical procedure• Understand that it doesn’t work in

everyone and the return to play time can be extensive


COMPARISON

• Much better than repair in professional athletes– Conway, et al. AJSM

• Excellent return to play in professional athletes (85 - 93%)– Cain, et al. AJSM 2012– Altchek, et al. AJSM


• Simple surgery and more rapid recovery

• Doesn’t have to miss a season

• Results are actually quite good: – Savoie, et al.: 58 / 60

RTP same or higher level: AJSM 2008

– Richard (Rusch), et al.: JBJS 2008

RECONSTRUCTION REPAIR

RECONSTRUCTIONQUESTIONS?

• Longevity of procedure? • Potential for re-injury? • What are the results of

revision reconstruction in athletes?


ANSWERS!• Average post-

reconstruction career is 3.5 years

• Potential for re-injury is undetermined

• Results of revision reconstruction are 30 - 40% return to play at best (Yocum, et al.)

ADVANTAGE OF REPAIR• The MUCL is an extra-

articular ligament and should heal like one (not an ACL), meaning 6 - 8 weeks to heal

• Altchek’s muscle-splitting approach (Smith, et al.) minimizes surgical damage and allows rapid rehab

• Protective bracing allows immediate scapular and core rehabilitation


SURGICAL TECHNIQUE• Prone position for

diagnostic arthroscopy• Internally rotate the

shoulder and place hand on a standard arm board for the open part

• Smith approach, split the muscle, evaluate ligament under direct visualization for area of damage


SURGICAL TECHNIQUEACUTE MUCL AVULSION


INITIAL MUSCLE SPLIT APPROACH

SURGICAL TECHNIQUE• Incise ligament along its

anterior margin to look at its underside

• Place an osteo-inductive or osteoconductive (not a biocomposite) anchor into humerus at the base of the medial epicondyle or middle of sublime tubercle for ulnar avulsion

• Double-mattress suture repair


SURGICAL TECHNIQUE


SURGICAL TECHNIQUE


SURGICAL TECHNIQUE

• Repair the capsule back over the repaired ligament in pants-over-vest suture – Watch out for ulnar

nerve along the back of the ligament

– Don’t pull capsule too far—must maintain full extension

– Should we add PRP?


SURGICAL TECHNIQUEREHABILITATION

• Splint for 1st week then hinged elbow brace for next 8 - 12 weeks.

• Start scapula, core, hip, and wrist rehab immediately

• Elbow rehabilitation in brace added at week 4

• Return to throw starts week 6 to 8 in brace and week 12 out of brace


RESULTS

• 2 studies both have >90% return to same or higher level of play– Not really better

than reconstruction, it’s a different group and they get older and stronger, this just doesn’t get in the way

MUCL INJURIESNON-OPERATIVE Rx

• Often effective in young athletes

• Must address all the bio-mechanical issues in throwing while protecting the ligament with bracing

• Biologic enhancement offers hope for the future


SURGICAL MANAGEMENT

• Repair is a viable option in young (age < 20) athletes with a single tear and an otherwise normal ligament

• Reconstruction is an excellent option with a high RTP when done correctly, regardless of specific technique or graft choice

MUCL INJURIESEVOLUTION

• Dugas has evolved the repair technique

• Internal brace with fibrin-coated suture is a “game changer” in the non-professional athlete

• MY SERIES

• 26 Dugas technique uclrepair

• Motion and stability reported as normal

• RTP has been 100% at 4 months

• Complication: 1 subluxating ulnar nerve


THANK YOU


Date post:	24-Jun-2020
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MUCL REPAIR - AOSSM · • Jobe reconstruction (“Tommy John” surgery) is standard of care •...

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