MUCL REPAIR. Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA

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1 MUCL REPAIR Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA

2 MUCL INJURY EPIDEMIC Frequency increasing despite major efforts at injury prevention Occurring in younger athletes Do we treat these young athletes like professionals?

3 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

4 Inspect for swelling Palpate for tenderness Valgus stress test in pron. and sup. Moving valgus stress test VEO test MUCL EXAM

5 MUCL MANAGEMENT Stop playing Play with pain Rest, brace, and rehab and let it heal PRP injections Repair Reconstruction Autograft vs. Allograft

6 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!

7 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

8 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

9 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

10 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.

11 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

12 COMPARISON RECONSTRUCTION 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 REPAIR 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 QUESTIONS? Longevity of procedure? Potential for re-injury? What are the results of revision reconstruction in athletes? ANSWERS!

13 RECONSTRUCTION QUESTIONS? Longevity of procedure? Potential for re-injury? What are the results of revision reconstruction in athletes? ANSWERS! Average postreconstruction 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.)

14 ADVANTAGE OF REPAIR The MUCL is an extraarticular 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

15 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

16 SURGICAL TECHNIQUE ACUTE MUCL AVULSION INITIAL MUSCLE SPLIT APPROACH

17 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

18 SURGICAL TECHNIQUE

19 SURGICAL TECHNIQUE

20 SURGICAL TECHNIQUE Repair the capsule back over the repaired ligament in pants-overvest 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?

21 SURGICAL TECHNIQUE REHABILITATION Splint for 1 st 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

22 MUCL INJURIES NON-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

23 MUCL INJURIES EVOLUTION 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 ucl repair Motion and stability reported as normal RTP has been 100% at 4 months Complication: 1 subluxating ulnar nerve

24 THANK YOU

MEDIAL ELBOW INSTABILITY

MEDIAL ELBOW INSTABILITY Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA Royalties: none Stock: none Stock option: Cayenne