Evolution of the Surgical Treatment of Ulnar Collateral Ligament Injuries

Since Dr. Frank Jobe performed the initial surgery on Tommy John in 1974, the ulnar collateral ligament (UCL) reconstruction (UCLR), colloquially “Tommy John Surgery,” described in 1986 has evolved as the gold standard treatment for UCL tears. The crux of technique modifications involve flexor pronator mass (FPM) management, ulnar nerve transposition (UNT), graft selection, or graft-fixation options. Jobe used a figure-of-8 graft fixation through the cubital tunnel, necessitating FPM elevation and UNT. Although 68% of patients returned to play (RTP), 25% of patients experienced ulnar neuritis, prompting change. Described by Thompson et al. in 2001, the modified Jobe technique implemented a muscle-splitting approach to the FPM, eliminating the need for FPM elevation, facilitating optional UNT. This technique uses larger tunnel sizes to facilitate graft passage in a figure-of-8 fashion. Graft selection is another consideration in UCLR. Most commonly, the palmaris longus autograft is used. In addition, there are no significant outcome differences between alternative graft types such as allografts, hamstring autografts, or extensor tendons. Notably, palmaris longus autograft is perhaps a high-risk choice, given the proximity to the median nerve. One case series reported 19 incidents of iatrogenic median nerve harvest. Lastly, the docking technique, from Altchek et al. in 2002, builds upon the modified Jobe. Using the FPM split, optional UNT enhanced graft passage and fixation with one humeral tunnel and smaller exit holes. This approach demonstrates a remarkable 90% RTP at 12 to 18 months, ultimately leading to satisfactory outcomes and potentially shorter operating room times. An alternative approach to UCLR, UCL repair with suture augmentation obviates the need for a graft, shortening RTP time to approximately 6 months. Historically, UCL repair indications were inconsistent; however, the current professional consensus suggests acute injuries, minimal ligamentous degeneration, or isolated proximal or distal avulsions may be optimal injury patterns for repair.