In recent years, the number of overhead throwing athletes with injuries to the ulnar collateral ligament (UCL) has increased. Historically, these injuries have been treated successfully with UCL reconstruction surgeries but because the injuries have become a near epidemic clinical problem, physicians at Andrews Sports Medicine in Birmingham developed a procedure to repair the UCL with internal brace augmentation. That, along with accelerated physical therapy, is returning athletes to the field of play more quickly.
"We hypothesized that using an internal brace to augment the repair of the native UCL would allow for a more aggressive physical therapy protocol and ultimately facilitate both an expeditious return to sports and a high level of patient satisfaction," says Jeffrey R. Dugas, MD, an orthopedic surgeon with Andrews Sports Medicine. "After a number of studies, we have performed about 100 of these surgeries which is about half of the total number that have been done throughout the United States. Because of its success, the procedure is gaining in popularity and our staff is training surgeons around the country."
Prior to this repair and augmentation procedure, UCL injuries typically were treated with a modified UCL reconstruction procedure commonly known as Tommy John surgery, named for the first patient to undergo the procedure.
Dugas says that Tommy John surgery is still a common procedure, because the new augmentation surgery doesn't work on everyone.
"The augmentation doesn't work on people with tissue deficiency. If the ligament tissue is not good quality or there is a missing piece of ligament, that person needs more tendon, more ligament or more tissue," he says. "90 percent of the patients who qualify for the augmentation repair are high school or college athletes who have good quality tissue. As a result, 80 to 90 percent of the Tommy John surgeries I do now are with the augmented repair on younger athletes."
Based on an earlier technique performed by Felix H. Savoie III, MD and his colleagues in 2013 in which he used suture anchors, Dugas and his fellow surgeons created a construct that could be used not only to repair the torn native UCL tissue to bone, but also to span the anatomic native ligament from its origin to its insertion. "The internal brace is basically two plastic suture anchors that are 3.5 millimeters wide and are spanned by two limbs of high-strength tape dipped in collagen to help speed up the healing process," Dugas says. "Using this construct, the native ligament disruption can be repaired directly to bone by placing the suture through the eyelets of the anchors. The remainder of the native ligament is augmented with the spanning-biologic enhanced tape."
A cadaver study done in 2013 showed that the augmentation was relative to the standard Tommy John surgery and, in some cases, better. "We felt comfortable putting this construct in a patient, but I needed the right patient to walk through the door - a rising senior pitcher who was injured playing summer ball in June and needed a ligament repair in order to play his senior season," Dugas says. "That kid walked into my office in June 2013. We tried to rehab him to avoid surgery but we couldn't. In August, he failed about eight weeks of conservative management, so we talked to the boy and his mother and explained the new procedure. They decided to go for it. The procedure and rehab went well, and he pitched his entire senior season and now is playing his second year of junior college ball."
The rehabilitation plan that the Andrews group designed to accompany this new procedure is key to the goal of achieving faster recovery times for these athletes, several of whom are professional ball players. Dugas and Kevin Wilk, DPT, head therapist at Champion Sports Medicine, developed a modified program that is based on the Tommy John surgery but is more aggressive. "Basically, we give the injury six weeks to heal before we start a four-week program of plyometric drills to put stress on the ligament. We let them throw at the end of week 10, which is two months sooner than the typical reconstruction rehab," Dugas says. "The average return from reconstruction is just more than 11 months. The average return to competition with this new procedure is just over six months. That cuts the recovery time almost in half, which is amazing. People have asked if we can do it even more quickly. I'm happy with six months, and I don't want to push it. I think we will be tempting fate if we try to go faster than that."
Dugas and his team are thrilled with the early success of this technique but are remaining cautious about older, higher-level athletes such as professional baseball players. "Right now, we don't have enough information or experience with the technique to say that we are comfortable expanding our indications to the more deteriorated ligaments that are seen in older throwers," he says. "This operation has worked well in younger athletes with good tissue to repair, but the expansion of the indications to older, more chronically injured elbows has not been evaluated thoroughly at this time."
Dugas expects the use of this new technique to increase, but he doesn't think it will completely replace the Tommy John surgery. "There will always be people who have tissue deficiency, so I don't think Tommy John surgery will ever go away. Our goal was not to replace that procedure. It is a good one that we have used for over 20 years, but not everyone needs that surgery," he says.
"We are coming up on three years that we have been doing the new repair and augmentation, and I haven't had a single patient who hasn't returned to at least the level he or she was at prior to the injury. Our success rate has been high for getting athletes back to at least the same or a higher level of performance. That's the benchmark we are holding ourselves to, and so far it's been successful."
