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Medial Ulnar Collateral Ligament Reconstruction (Tommy John Surgery)

Tommy John surgery, known in medical practice as ulnar collateral ligament (UCL) reconstruction, is a surgical graft procedure in which a ligament in the medial elbow is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, hip, knee, or foot of the patient). The procedure is common among collegiate and professional athletes in several sports, most notably baseball.

The procedure was first performed in 1974 by Dr. Frank Jobe, who today serves as a Special Advisor to the Los Angeles Dodgers, and is named after former major league pitcher Tommy John, whose 288 career victories ranks seventh all time among left-handed pitchers.

What is Medial Ulnar Collateral Ligament Injury at the Elbow?

Ligaments join bone to bone. The medial ulnar collateral ligament connects to two bones in the arm, the ulna, the large bone of the forearm found on the little finger side of the arm and the humerus, the large bone of the upper arm. The ulnar collateral ligament, a triangular piece of tissue, consists of three parts: the anterior bundle, posterior bundle and transverse ligament, which is thinner than the other two. Ligaments can rupture or tear if you apply excessive force to them.

What causes a medial collateral ligament injury?

Medial ulnar collateral ligament injury at the elbow is a complete or partial tear in the ligament. Medial ulnar collateral ligament tears can interfere with use of the arm as well as causing pain, numbness and tingling and swelling on the inner part of the elbow. If you have this type of tear, you can still use the arm, but you can’t throw as forcefully. Acute strain on the ligament, such as a sudden pulling force can tear or completely rupture a tendon. Repetitive motions such as throwing a ball can also damage the ligament over time. Ballplayers who throw overhand are especially prone to this injury; non-athletes can also sustain this type of tear, although this occurs less frequently.

Treatment options for medial collateral ligament injury

Treatment for medial collateral ligament injury depends on the severity of the tear and the symptoms. Microscopic tears in the ligament will heal within a few weeks with rest, ice to reduce swelling, non-steroidal anti-inflammatory medications to reduce inflammation, pain and swelling and physical therapy to strengthen the weakened tendon. A complete tear will not heal without surgical intervention.

How is medial collateral ligament surgery done?

The surgical treatment for a medial collateral ligament tear is often known as Tommy John surgery, a name that refers to the first athlete who benefited from the surgery in 1974. The surgery is done through a small incision on the inner part or medial side of the elbow joint. In some cases, the surgeon may perform an arthroscopy before doing the surgery to repair the ligament. In this procedure, your doctor inserts several small cameras through small incisions in the elbow joint. Through these incisions, he can look for loose bone fragments or bone spurs and remove them.

For the actual reconstruction procedure, your surgeon will replace the damaged ligament with a tendon from your own body. The tendon may be removed from your arm, knee, foot or hamstring. Using tissue from your body to repair another area of your own body is called an autograft. The muscles inside the elbow and forearm, called the flexor muscles, are split and pulled back, or retracted, to reach the damaged ligament.
After removal of the damaged ligament, the grafted tendon must be attached to the structures in the arm. This can be done using one of several techniques to attach the tendon to the bones. The docking and figure of eight techniques involve drilling holes in the ulna and medial epicondyle, the small bump at the end of the humerus and looping the grafted tendon through the tunnels created by the holes.

Recovery time

Complete medical collateral ligament surgery recovery time can be long, up to 9 to 12 months for complete return of function and ability to use the arm without further injury, especially if you’re a pitcher. In some cases, you may be able to start working with the arm within six months. Your surgeon may immobilize the arm for the first week or so and then begin range of motion exercises working with a physical therapist. Complete recovery occurs in around 85 to 90 percent of cases.