Post-Operative Instructions Open Elbow Surgery, Ulnar Collateral Ligament Reconstruction Tommy John Surgery

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1 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery T Day f Surgery Pst-Operative Instructins Open Elbw Surgery, Ulnar Cllateral Ligament Recnstructin Tmmy Jhn Surgery A. Diet as tlerated. B. Pain medicatin as needed every 6 hurs. C. Icing is imprtant fr the first 5-7 days pst-p. While the pst-p dressing is in place, icing shuld be dne cntinuusly. Once the dressing is remved n the first r secnd day, ice is applied fr 20-minute perids 3-4 times per day. Care must be taken with icing t avid frstbite. D. Make sure yu have a physical therapy pst-p appintment set up fr the first week-10 days after surgery. E. If yu have a splint r half cast, yu will start PT after the splint is remved in the ffice at yur first pstperative appintment which is usually at 2 weeks First Pst-Operative Day A. Cntinue icing B. Yu will need t keep yur incisin dry when taking a shwer. D this fr abut 2 weeks after surgery. If yu have a splint r half cast (hardshell) leave it dry. N need t d dressing changes until yur first fllwup visit at 2 weeks pst-p. Secnd Pst-Operative Day A. Cntinue icing Third Pst-Operative Day Until Return Visit A. Cntinue ice pack as needed. B. If yu dn t have a split r half cast, yu may remve surgical bandage after yu shwer and apply a waterprf bandage (may be purchased at yur lcal pharmacy) t the wunds. Please ensure that the bandage is large enugh t cmpletely cver the incisin. Apply a fresh waterprf bandage after each shwer. If yu have splint yu d nt need t change anything. Keep extremity dry Call ur ptin 4, ptin 2 t cnfirm yur first pstperative visit, which is usually abut 1-2 weeks after surgery. If yu are experiencing any prblems, please call ur ffice r cntact us via the internet at NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F

2 Dr. Laith M. Jazrawi Assciate Prfessr Department f Orthpaedic Surgery Rehabilitatin Prtcl Fllwing Ulnar Cllateral Ligament Recnstruc5n Using Autgenus Gra8 The elbw is a cmplex system f three jints frmed frm three bnes; the humerus (the upper arm bne), the ulna (the larger bne f the frearm, n the small finger side), and the radius (the smaller bne f the frearm n the thumb side). This cmplex system allws a hinging ac?n (bending and straightening) and a rta?n ac?n. The stability f the elbw jint is maintained by the bny cngruency, the muscular a@achments and the ligaments. There are several imprtant ligaments in the elbw. Ligaments are sc?ssue structures that cnnect bnes t bnes. The ligaments arund a jint usually cmbine tgether t frm a jint capsule. A jint capsule is a water?ght sac that surrunds a jint and cntains lubrica?ng fluid called synvial fluid. In the elbw, tw f the mst imprtant ligaments are the ulnar cllateral ligament (UCL) and the lateral cllateral ligament (LCL). The UCL is als knwn as the medial cllateral ligament. The UCL is n the medial (the side f the elbw that s next t the bdy when yur arms are at yur side with yur palms up r facing ut in frnt f yu) side f the elbw and LCL is n the utside f yur elbw. The ulnar cllateral ligament is a thick band f?ssue that frms a triangular shape alng the inside f the elbw. It has an anterir bundle, psterir bundle, and a thinner, transverse ligament. These ligaments can be trn when there is an injury r dislca?n f the elbw. If the injury t the ligament(s) affects the stability f the jint, it is pssible that the func?n f the elbw will be cmprmised. Injury t the UCL in verhead athletes has been widely reprted. Nrmal ac?vi?es f daily living rarely place enugh stress n the UCL t create instability; hwever thrwing sprts place high stresses n the elbw suppr?ng structures. Over?me, the high repe??ve stresses assciated with thrwing and verhead ac?vity may create verlad t the suppr?ng ligamentus supprt, resul?ng in a UCL tear. Typically, athletes with UCL injury reprt a histry f repe??ve thrwing with cmplaints f pain at the medial (inside) aspect f the elbw during r acer their ac?vity. Onset ccurs frm either ne trauma?c incident r can develp thrughut a lng perid f?me due t repe??ve elbw stress. Eventually the athlete lses their velcity and accuracy f thrwing. Mre than 40% f athletes with UCL injury als reprt symptms f ulnar nerve irrita?n frm fric?n r snapping f the nerve during ac?vity. The verhead thrwer Cen experiences pain with the arm fully ccked (shulder in full external rta?n r the arm rtated all the way back) and as it accelerates thrugh the thrw and release f the ball. While thrwing, the elbw can straighten at speeds f ver 2300 degrees per secnd and may have a valgus (side) frce that exceeds the ul?mate strength f the nrmal uninjured UCL. Therefre, prper mechanics and p?mal strength and endurance f the muscles f the upper extremity are needed t assist with injury preven?n. Trauma r injury t the UCL results in significant func?nal limita?ns including medial elbw pain, lss f velcity and accuracy with thrwing, instability, neurlgic (nerve) symptms, and decreased muscular strength. The cnsequences f this injury usually leave the athlete wh has a trn UCL with tw p?ns: 1) rehabilita?n with ac?vity mdifica?n (i.e. avidance f pitching and perfrmance thrwing) r 2) surgical recnstruc?n with pstpera?ve rehabilita?n prir t return t pitching and perfrmance thrwing. UCL recnstruc?n surgery is perfrmed thrugh an incisin n the medial (inside) side f the elbw jint. The damaged ulnar cllateral ligament is replaced with a tendn taken frm smewhere else in the bdy. The tendn grac can cme frm the pa?ent s wn frearm, hamstring, knee r ft. This is called an autgrac. This tendn is weaved thrugh drill hles in the humerus and ulna t re-create the triangular shape f the UCL th St. New Yrk, NY (646) newyrkrth.cm!

3 Rehabilitatin Prtcl After Elbw UCL Recnstructin One cmmn technique used t replace the damaged ulnar cllateral ligament is called the dcking technique. The surgen drills tw hles in the ulna and three in the medial epicndyle f the humerus (the small bump f bne n the inside f the elbw at the b@m f the upper arm). The tw hles in the ulna frm a tunnel that the tendn grac will be lped thrugh. The three hles in the medial epicndyle frm a triangle. The b@m hle will be bigger than the tp tw hles, s that the surgen can slide the end f the tendn grac int the b@m hle. The tw tp hles are used t pull the tendn grac int the tunnel using sutures that are a@ached t the grac and threaded thrugh the tw hles. ACer the tendn is harvested, sutures are a@ached t bth ends. The tendn is lped thrugh the lwer tunnel frmed in the ulna, and stretched acrss the elbw jint. The tw sutures a@ached t the ends f the grac are threaded int the larger b@m tunnel in the medial epicndyle and each is threaded ut ne f the upper, smaller hles. Using these tw sutures, the surgen pulls the end f the grac farther int the upper tunnel un?l the amunt f tensin is crrect t hld the jint in psi?n. The surgen carefully puts the elbw thrugh its full arc f m?n and readjusts the tensin n the sutures un?l sa?sfied that the prper ligamentus tensin is restred. The tw sutures are?ed tgether t hld the tendn grac in that psi?n. Anther cmmn technique t recnstruct the UCL is called the figure f eight technique. In this technique, the tendn grac is threaded thrugh tw pairs f hles - tw drilled in the medial epicndye f the humerus and tw in the ulna. The grac is lped thrugh the hles in a figure f eight fashin. The tw ends f the tendn are sutured t the tendn itself. Previusly the muscles n the inside f the elbw jint and frearm (the flexr muscles f the wrist) were cmpletely detached frm the humerus. Nw, the flexr muscles are nt detached, but are split and retracted t allw the surgen t see the areas f the elbw jint required t perfrm the pera?n successfully. If there is any cncern that the ulnar nerve has been stretched and damaged due t the instability (as men?ned abve), it may be re-ruted s that it runs in frnt f the elbw jint rather than thrugh the cubital tunnel in the back f the elbw. The incisin is sutured tgether and the elbw is placed in a large bandage and splint. Rehabilita?n fllwing surgical recnstruc?n f the UCL begins with range f m?n and ini?al prtec?n f the recnstruc?n, alng with resis?ve exercises t keep the shulder and cre strng. This is fllwed by prgressins fr resis?ve exercise that a@empt t fully restre strength and muscular endurance t allw fr a safe return t thrwing and verhead func?nal ac?vi?es. These guidelines als include aerbic training thrughut the rehabilita?n prcess and, fr many, a later stage an interval thrwing prgram. This mul?-faceted rehabilita?n apprach Cen includes bimechanical vide analysis t ensure prper thrwing mechanics befre an athlete returns t their sprt. The early phases f pst-pera?ve care fr UCL recnstruc?ns invlve specific?me frames, restric?ns and precau?ns t prtect healing?ssues and the surgical fixa?n/recnstruc?n. The later phases f rehabilita?n are presented in a criterin based prgressin, where advancement t subsequent levels is based n strength and cntrl. Return t cmpe??ve thrwing will take 8-12 mnths. Nt all athletes will be able t return t cmpe??ve thrwing. The athlete shuld ice the elbw fr minutes acer their rehabilita?n prgram t help decrease pain and swelling th St. New Yrk, NY (646) newyrkrth.cm!

4 Rehabilitatin Prtcl After Elbw UCL Recnstructin Phase I (Surgery t 4 weeks after surgery) Gals Prtect healing tissue Retard muscle atrphy Decrease pain/inflammatin Week 1 Psterir splint at 90 elbw flexin fr 7 days Brace: applicatin f functinal brace set at at day 7-10 after splint remved ROM: wrist AROM extensin/flexin Elbw cmpressin dressing 2-3 days Exercises: gripping, passive wrist ROM, shulder ismetric (n shulder ER), biceps ismetrics, crytherapy Week 2 Brace: elbw ROM in brace Gradually increase ROM 5 extensin and 10 flexin per week Exercises: cntinue all exercises listed abve Initiate elbw extensin ismetrics Week 3 Brace: elbw ROM Exercises: cntinue all exercises listed abve, elbw ROM in brace, initiate active ROM wrist and elbw (n resistance) Phase II (4 weeks t 7 weeks fllwing surgery) Gals Gradual increase t full ROM Prmte healing f repaired tissue Regain and imprve muscular strength Week 4 Brace: elbw ROM Exercises: begin light resistance exercises r arm (1 lbs), wrist curls, extensins, prnatin, supinatin, elbw extensin/flexin Prgress shulder prgram t emphasize rtatr cuff strengthening, aviding eternal rtatin until week 6 Week 5 ROM: elbw ROM D/C brace Cntinue all exercises Week 6 ROM: withut brace r full ROM Exercises: prgress elbw strengthening exercises, initiate shulder external rtatin strengthening Week 7 Initiate Thrwer s Ten Prgram Prgress light istnic prgram th St. New Yrk, NY (646) newyrkrth.cm!

5 Rehabilitatin Prtcl After Elbw UCL Recnstructin Phase III (8 weeks t 13 weeks fllwing surgery) Gals Imprve strength/pwer/endurance Maintain full elbw ROM Gradual return t functinal activities Weeks 8-10 Exercises: initiate eccentric elbw flexin/extensin, Cntinue istnic prgram (frearm and wrist), Shulder prgram (Thrwer s Ten), Stretching prgram (especially elbw extensin) Phase IV (14 weeks t 32 weeks fllwing surgery) Gals Cntinue t increase strength, pwer and endurance f upper extremity musculature Gradual return t activities Week 14 Exercises: cntinue strengthening prgram, emphasis n elbw and wrist strengthening and flexibility exercises Maintain full elbw ROM Week 16 Exercises: initiate interval thrwing prgram (Phase I), cntinue all exercises Stretch befre and after thrwing Weeks Exercises: prgress t Phase II Thrwing Prgram (nce Phase I cmplete) Week 30 Exercises: prgress t cmpetitive thrwing References th St. New Yrk, NY (646) newyrkrth.cm!

6 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery T Pst Operative Rehabilitatin Prtcl Fllwing Ulnar Cllateral Ligament Recnstructin Using Autgenus Graft Name: Diagnsis: Date: Date f Surgery: Phase I Immediate Pst Operative Phase Gals Prtect healing tissue Retard muscular atrphy Decrease pain/inflammatin Week 1 Psterir splint at 90 elbw flexin fr 7 days Brace: applicatin f functinal brace set at at day 7-10 after splint remved ROM: wrist AROM ext/flexin Elbw cmpressin dressing 2-3 days Exercises Gripping Wrist ROM (passive nly) Shulder ismetrics (n shulder ER) Biceps ismetrics Crytherapy Week 2 Brace: Elbw ROM in brace Gradually increase ROM 5 ext and 10 f flexin per week Exercises Cntinue all exercises listed abve Elbw ROM in brace Initiate elbw extensin ismetrics Week 3 Brace: Elbw ROM Exercises Cntinue all exercises listed abve Elbw ROM in brace Initiate active ROM wrist and elbw (n resistance) Phase II Intermediate Phase (Week 4-7) Gals Gradual increase t full ROM Prmte healing f repaired tissue Regain and imprve muscular strength Week 4 Brace: elbw ROM NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F

7 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery T Exercises Begin light resistance exercises r arm (1 lbs) Wrist curls, extensins, prnatin, supinatin Elbw ext/flexin Prgress shulder prgram t emphasize rtatr cuff strengthening Avid external rtatin until week 6 Week 5 ROM: elbw ROM Discntinue brace Cntinue all exercises Week 6 ROM: withut brace r full ROM Exercises Prgress elbw strengthening exercises Initiate shulder external rtatin strengthening Week 7 Initiate Thrwer s Ten Prgram Prgress light istnic prgram Phase III Advanced Strengthening Prgram (Week 8-13) Gals Imprve strength/pwer/endurance Maintain full elbw ROM Gradual return t functinal activities Week 8-10 Exercises Initiate eccentric elbw flexin/extensin Cntinue Istnic prgram frearm and wrist Shulder prgram Thrwer s Ten Stretching prgram especially elbw extensin Week Exercises Cntinue all exercises listed abve Initiate plymetric exercise prgram Phase IV Return t Activity (week 14-32) Gals Cntinue t increase strength, pwer, and endurance f upper extremity musculature Gradual return t activities Week 14 Exercises: cntinue strengthening prgram Emphasis n elbw and wrist strengthening and flexibility exercises Maintain full elbw ROM NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F

8 Laith M Jazrawi, MD Prfessr f Orthpedic Surgery T Week 16 Exercises Initiate interval thrwing prgram (phase I) Cntinue all exercises Stretch befre and after thrwing Week Exercises Prgress t Phase II Thrwing Prgram (nce cmpleted Phase I) Week 30 Exercises Prgress t cmpetitive thrwing Cmments: Frequency: times per week Duratin: weeks Signature: Date: NYU Langne Orthpedic Center 333 E 38th St, New Yrk, NY T F